
Class _iLB_U3 
Book R4 r l — 



COPYRIGHT DEPOSIT. 



APPLIED PHYSIOLOGY. 



A MANUAL SHOWING FUNCTIONS OF 
THE VARIOUS ORGANS IN DISEASE. 



BY 

FREDERICK A. RHODES, M. D., 

'» 

PROFESSOR OF PHYSIOLOGY AND EMBRYOLOGY, MEDICAL AND 

DENTAL DEPARTMENTS OF THE WESTERN 

UNIVERSITY OF PENNSYLVANIA. 

LATE PHYSICIAN-IN-CHARGE TO THE REINEMAN HOSPITAL AND 
THE KAUFMAN CLINIC. 

FORMERLY ASSISTANT TO THE CHAIR OF CLINICAL MEDICINE, 
WEST PENN MEDICAL COLLEGE, Etc. 



1907. 

MEDICAL PRESS, 

PlTTSBUEG, PA. 



<&£\ 



lUBRARY of CONGRESS] 
Two CoplM Receive 

JAN 171908 

Copyngnt trtry 

SCLASSA, XXC No. 
COPY 6. 



Copyright 1907. 
Medical Press. 



PREFACE. 

I have attempted in this volume to present to the 
student of medicine, whether in school or in practice, an 
explanation of the most important and frequent symptoms 
of diseases met with. Much of the work is given in out- 
line, as it is believed it will be more acceptable to the eye 
and hence more easily remembered. As far as possible a 
general introduction to each subject, mentioning some of 
the important physiological laws and their consideration 
from the standpoint of the practicing physician, is given. 

The need of such a work as this has long been recog- 
nized by the profession. There is no American text on this 
subject so far as I can learn. Some European writers treat 
the subject in a general way ; much of their excellent books 
being taken up in discussion of various theories of disease 
and symptoms. Prof. Winfield S. Hall, Northwestern Uni- 
versity, Chicago, has written several excellent articles on 
the importance of such a book. He has embodied his ideas 
in his text-book on physiology, adding to each chapter a 
treatise of the various organs when their function is altered. 
The title, "Applied Physiology," was first suggested in an 
article by Dr. J. Madison Taylor in the Medical News, May 
13, 1905. 

The subject of Aoolied Physiology was made a part of 
the regular course in the Medical Department of the West- 
ern University of Pennsylvania three years ago; the recep- 
tion given it by the faculty and the members of the pro- 



4 PREFACE. 

fession has been better than could have been anticipated. 
It teaches the student to understand why many a symptom 
exists ; he does not take everything for granted and is the 
better able to use a drug when indicated. He will the more 
frequently endeavor to remove the cause of the condition 
rather than treat the symptom itself. 

It seems profitable to add here some abstracts from a 
lecture on the blood delivered before the College of France 
in 1837, by Magendie. While he was an iconoclast, yet the 
statements contain some terse remarks which may stimulate 
thought at the present time. 

"Are you not in truth convinced — you who have many 
a time ascertained the fact for yourselves — that the lesions 
found at our autopsies are frequently produced after death, 
and that, consequently, the plan hitherto followed in such 
inquiries is fallacious, and can only lead to vague informa- 
tion and error? * * * Devote yourself, on the contrary, 
to experimental study, see, touch for yourselves, take no 
one's word for anything, mistrust yourselves, mistrust me 
and you will manage to steer clear of the whimsical concep- 
tions brought forward to explain, some way or other, the 
frequently inexplicable phenomena of organization. * * * 
But do you imagine that the nurse, provided she be habitu- 
ated to her calling, does not know all that quite as well as 
he? Will he be able to tell me a whit more correctly than 
she why the case of variola before him will prove confluent 
or benign? Or why the skin, suddenly assuming a purple 
color, the sufferer is carried off in a few hours? * * * 
Be persuaded of this, gentlemen, that the truly scientific 



PREFACE. 



mode of studying medicine lies almost wholly in investi- 
gating the manner in which morbid changes are produced. 
* * * Well, they ascribe the malady to these lesions, 
but they are wrong. These are consequences of the disease, 
the anatomical proofs that it has existed. But they are not 
its starting point, and it is manifest that with our present 
knowledge and with the present mode of studying pathology 
that starting point will never be discovered. * * ' * For my 
part, I declare loudly that I look on these ideas about vitality 
and the rest of it as nothing more than a cloak for ignorance 
and laziness * * * The prevalent mode of treating dis- 
ease harmonizes admirably with, and is quite as senseless as, 
this method of reasoning in pathology. The practitioner 
mixes, combines and jumbles together vegetable, mineral 
and animal substances ; administers them right or wrong, 
without considering for a moment the cause of the disease, 
and without a single idea on the why and wherefore of his 
conduct. You may prove to him, as you will, that this or 
that substance is insignificant, useless, or even hurtful ; little 
will he regard your expostulation.. And why should he, 
when by readiness in prescribing a monstrous farrago of 
drugs, he knows he shall acquire the reputation of being 
profoundly versed in materia medica, of being a man of 
immense resources, etc. Such, gentlemen, has ever been 
empiricism." 

In the effort to make this work as practical as possible 
I have gleaned thoroughly from the various writers on 
physiology, pathology, medicine, diagnosis, specialties, as 
well as the current medical literature. 

I have attempted to give credit where credit is due, 



6 PREFACE. 

and I append a list of the books from which I have taken 
much of the material. It has been found impossible to state 
from which book the various abstracts have been taken in 
many instances, as they were not made for the purpose for 
which I now use them. I am very greatly indebted to Prof. 
Hall of Chicago for his advice at different times, to Dr. C. 
H.. Henninger for several pages on symptoms in nervous 
diseases and to Dr. C. B. McAboy, assistant in physiology, 
for valuable assistance. 

Should the efforts spent in the production and in the 
study of this book lead to a better knowledge of disease, 
even though it be little, I shall be well repaid. 

Frederick A. Rhodes. 

November i, 1907. 



CIRCULATION 



CHAPTER I. 

CIRCULATION. 

The circulatory apparatus consists of the heart, 
blood, blood vessels and nerves, and is for the purpose 
of carrying blood to and from the various organs and 
tissues. In order that the functions of the body may be 
properly carried out it is necessary that not only the 
circulatory apparatus itself, but also the tissues to be 
supplied, be in normal condition. 

The blood may be normal and contain all the sub- 
stances in proper proportion for the supply of the tissues ; 
the heart, vessels and nerves may be in perfect condition, 
yet if for any reason any tissue cannot appropriate the 
nourishment nor give up its waste products, harmony is 
lost, and the whole organism suffers to a certain degree 
in a short time. Theoretically and practically it is en- 
tirely wrong to state that the circulatory apparatus can 
long be normal, and the kidneys, liver, spleen, etc., be in 
a diseased condition. Chemically, it is often impossible 
to detect these secondary changes until after the diseased 
condition has existed for some time. In a like manner 
we cannot conceive of any important blood changes, 
either in alteration of the number of the corpuscles, 
amount of contained haemoglobin, or nutritive substances 
which are contained in the plasma, without the heart and 
tissues suffering in consequence of such changes. 

These few remarks apply to any and all of the tissues 



8 APPLIED PHYSIOLOGY 

in the body, although it may appear that certain parts, as 
a limb, the spleen, ovaries, etc., may be removed without 
any apparent changes in the remaining tissues or altera- 
tion in the normal function in general. In those cases 
where no changes are noticed compensation is so well 
provided for by nature that the body may suffer but 
little. Thus, when a kidney is removed, the remaining 
one will hypertrophy and apparently do the work pre- 
viously done by the two. But the loss of certain parts 
by disease or removal is not always followed by such 
negative results. The relations of one part of the body 
to the other parts are seen in what may appear to be a 
slightly diseased condition, when in reality the meta- 
bolism of the entire organism may be altered. Recent 
advances in our knowledge of internal secretions have 
assisted us much in the study of many conditions. 

It will be important in our studying the altered 
action of the various parts of the body to bear in mind 
the close relation existing between the different organs, 
the tissues and the blood, i. e., to be ever mindful of the 
normal physiologic action and the tissue correlation. 

THE HEART. 

The heart is so situated and constructed that it will 
furnish the most kinetic energy with the least possible 
muscular exertion. Any alteration in the output of the. 
heart requires either an increased activity, by a greater 
number of beats, or an increase in the size of the organ 
to perform the normal amount of work. 

It is true that at times this relative amount of work 



CIRCULATION. 



done by the heart and the normal requirements may seem 
to vary markedly, as in acute infectious fevers, but in 
these cases the other organs are overworked at the same 
time. In order that the normal may be re-established 
the somewhat similar correlation of the various organs 
is still in evidence, but on a different basis of activity. 

The normal rhythm of the heart's action is controlled 
chiefly by the following factors : 

i — The musculature. 
2 — Innervation. 
3 — Blood. 
4 — Resistance. 

The variation from the normal in any of these is 
apparent from the work done by the heart. 

Musculature. — The arrangement of both the internal 
and external layers of muscular fibers is such that when 
contraction is initiated at the mouths of the great vessels 
it is continuous from the base to the apex, causing the 
heart to become shorter and thicker, with the force at the 
height of the contraction directed internally upon the 
blood in the ventricles. In the wave of contraction it is 
presumed at the present time that the "muscular bundle 
of His," which extends from the inter-auricular septum 
across the aurico-ventricular partition to the inter-ven- 
tricular septum plays a very essential part, alterations 
of which permit an alteration in the ratio of auricular to 
ventricular contractions, as is seen in Stokes-Adams 
syndrome. 

In connection with the musculature of the heart we 



10 APPLIED PHYSIOLOGY 

have the valve.s so adjusted between the auricles and ven- 
tricles., and in the openings of the aorta and pulmonary- 
arteries that the respective compartments are closed off 
from the blood stream, the blood is impelled forward and 
the heart is able to get the required rest — the period of 
diastole — when all contraction ceases and both the semi- 
lunar and auriculo-ventricular valves are closed. 

Anything which will oppose the current of blood as 
it leaves the heart, or any changes in the valvular action 
which prevents all of the blood from easily leaving the 
heart will have a tendency to increase the number and 
strength of contractions, or both, meaning, that if these 
conditions are long continued the heart muscle must 
hypertrophy in order to do the work required. 

The most important causes of overactivity of the 
musculature leading to hypertrophy are: 

i — Long continued muscular exertion. 

2 — Valve changes — 

(a) Stenosis — difficult exit. 

(b) Regurgitation — incomplete emptying (?) 

3 — External resistance — 

(a) Diseased blood vessels, including aneurysm. 

(b) Peripheral resistance in organs, as the liver, 
kidney, etc. 

(c) Continued vaso-constrictor action as in over- 
activity of adrenals, reflex action and others. 

4 — Long-continued augmentation through the nerv- 
ous system. 



CIRCULATION 11 



5 — Abnormal conditions in the pericardial sac : effu- 
sions and adhesions. 

Cardiac Dilatation. — This condition has called forth 
much discussion in the past. Clinically, while certain 
parts of the heart may appear dilated, i. e., the muscular 
fibers have lost their power to shorten normally on con- 
traction and are elongated and show at times fatty de- 
generation, other parts of the heart are still undergoing 
hypertrophy, and show an elongated condition at the same 
time. 

Dilatation, i. e., the enlargement of the cavities due 
to loss of muscular power, resembles very much the con- 
dition of muscle fatigue, and unless the material for the 
muscle energy can be supplied and the waste removed 
by the blood vessels to and from the heart muscles de- 
generation must take place. 

In order that the heart muscle may be properly 
nourished the branches of the coronary arteries must be 
able to furnish more fuel and the coronary veins take up 
more waste and maintain their relation to the parts sup- 
plied. Coincident hypertrophy and dilatation must neces- 
sarily refer to the gross appearance of the heart. 

Closure of the valves of the heart essentially depends 
upon intact condition of musculature. — Krehl. 

Location of the apex beat may be altered by: 

Change in size of the heart. 

Effusions in the pericardial sac ; also into the pleural 
cavities. 



12 v APPLIED PHYSIOLOGY 

Tumors. 

Pulmonary diseases. 

Changes in the abdominal viscera. 

Ascites. 

SPECIAL CIRCULATORY CONDITIONS. 

Heart Rhythm. — The normal rhythm implies the 
relative rate and action between the auricular and ven- 
tricular contraction as well as the diastole of the heart. 

Arrhythmia, or irregular heart, shows weak systole, 
dropped beat and an intermittent pulse. The absence 
of the systolic pulse is seen at times in the obese and is 
not pathologic. 

Heart Sounds. — First — Dull, booming, loudest at 
apex, caused by : 

(a) Valvular vibrations. 

(b) Impact and resistance of blood on semilunar 
valves. 

(c) Muscular sound on contraction. 

(d) Impulse of heart against chest wall. 

Second — Short, sharp, loudest at junction of right 
costal cartilage with sternum, caused by vibrations of the 
semi-lunar valves suddenly closing. 

Feeble first sound is due to : 

Degeneration of the heart muscle. 
Diminished volume of the blood. 
Nervous conditions. 



CIRCULATION. 13 



Accentuated second heart sound shows greater mus- 
cular action. 

Accentuated second pulmonary sound — due to hyper- 
emia and excessive tension in the pulmonary circulation. 

Reduplication of Heart Sounds — 

First or second sound my be reduplicated or split 

into two parts. 
Generally it is the second sound, heard over the base. 
First more frequently. — Pillsbury. 

Normally reduplication can be heard if the breath be 
held, at the close of inspiration. 

The phenomenon may disappear simultaneously with 
an improved condition of the heart. 

In many normal persons with a thin chest wall, a 
reduplication is present, while it is rare in per- 
sons with a thick chest wall. 

Excessive use of tobacco or alcohol will undoubtedly 
produce reduplication. 

The first sound may be reduplicated and the theo- 
retical causes are: 

(a) Hemisystole ; separate and independent con- 
traction of the two ventricles — asynchronous 
contraction. 

(b) Components of the first sound on each side 
do not fall together. In either case the 
cause is due to an increase of pressure in the 
ventricle. 



14 APPLIED PHYSIOLOGY 

Reduplication of the first sound means that the heart 
is not working properly. This may be due to 
nervous interference, or the heart may be hamp- 
ered by external agencies, or the heart muscle 
may not be efficient. 

The second sound may be reduplicated when there 
is an alteration of the blood pressure in either aortic or 
pulmonary systems. Thought to be due to the comple- 
tion of the systole of one side of the heart sooner than that 
of the other side. 

Gallop or Canter Rhythm. — This resembles so close- 
ly hoof-beats that it is called the Bruit-de-gallop. It is 
due to the interpolation of a third sound producing an ap- 
parent reduplication of either the first or second sound. 
This is due to : 

(a) An increase in the elastic resistance of the 
ventricular wall over its muscular tonicity. 

(b) The contractions of the papillary muscles 
taking place permanently, i. e., also during 
diastole. 

Whatever the cause, there is evidently abnormal 
pressure within the ventricle, and hence a dangerous ten- 
sion of its wall. It indicates a serious prognosis in 
chronic nephritis, due to the giving away of the left 
ventricle. 

Heart Murmurs — 

They are due to the blood stream being thrown into 
eddies or oscillations, or due to friction associated 



CIRCULATION 15 



with circulatory disturbances and to valvular 
changes. 

They are divided into endocardial and exocardial. 

The endocardial are divided into : 

(a) Organic, or structural. 

(b) Functional or accidental, haemic, dynamic, 
anemic. 

Endocardial Organic — 

The blood is thrown into eddies or currents, which 
generate vibrations which are audible. 

The conditions producing the murmurs are : 

(a) Constriction of the coats of the artery by 
external pressure. 

(b) Projection into the lumen of calcareous 
plates or masses capable of turning the blood 
stream from its direct course. 

(c) Aneurysms and vascular dilatation. 

(d) Changes in the orifices and valves of the heart. 

The intensity of murmurs bears a direct ratio to 
the amplitude of the vibrations in the blood stream; 
the intensity is not a criterion of the gravity of the 
lesion. 

The pitch depends upon the rapidity of the vibrations 
producing the murmur. 

Transmission of murmurs is along the surrounding 
solid media, and in the general direction of the 
blood stream producing the murmur. 



16 APPLIED PHYSIOLOGY 

Functional Murmurs — 

Heard in anemia and cardiac neuroses. 

They are systolic, blowing in character generally, and 
more frequently heard over the base. 

The cause of these murmurs is not known, but it is 
thought profitable to mention a few of the many 
theories advanced as to the cause. 

(a) Due to a mitral regurgitation, propagated in 
a different direction from the organic mur- 
murs. 

(b) A narrowing of the pulmonary artery by 
pressure of a dilated left auricle. 

(c) Tricuspid regurgitation, with dilated right 
ventricle. 

(d) Pressure upon the pulmonary artery by 
dilated or flabby heart. 

(e) Sudden discharge of a large wave of blood 
of abnormal composition into the probably 
dilated artery. 

(f) Right ventricle weakness; tremors at over- 
strained portion of ventricle. 

(g) Transmission of venous murmurs from the 
great veins to the heart. 

(h) That they are generated by impulse of heart 
apex against the lung. 

(i) Defective action of the papillary muscles or 

faulty insertion of the valve muscles, 
(j) That they are of haemic origin. 



CIRCULATION 17 



BLOOD PRESSURE. 

The factors concerned in the regulation of blood 
pressure are: 

(a) Energy of the heart. 

(b) Peripheral resistance. 

(c) Elasticity of the vessel walls. 

(d) Volume of blood. 

(e) Condition of the nervous system. 

An increased volume of blood from the heart is fol- 
lowed by a rise in pressure and a diminution in the out- 
put of the heart is followed by a fall, provided the resist- 
ance remains the same. 

Blood pressure is regulated automatically by reflex 
action, chiefly through t*»^ depressor filaments in the 
vagus. 

A too great increase in the peripheral resistance will 
cause a lesser output of the ventricles. 

Normally the tone of the vessels depends upon the 
balance between the opposing action of the two sets of 
nerves, vasoconstrictors and the vasodilators. 

Absence of the vasomotor tone is followed by stagna- 
tion of blood in the veins and eventually failure of the 
heart, no blood being brought to it. 

The abdominal vessels, supplied by the splanchnic 
nerves, have the greatest effect on general blood pressure. 

Blood pressure is influenced by mental and physical 
exercise, respiration, diet, emotion, etc. 

"Injection of salines into the circulation of a Jiving 



18 APPLIED PHYSIOLOGY 

animal raises the venous pressure proportionately more 
than the arterial ; capillary blood pressure depends more 
upon the venous pressure than upon the arterial pres- 
sure; a fall of arterial pressure does not necessarily in- 
volve a fail in the capillary pressure. The input and the 
venous pressure vary directly with the mean arterial 
blood pressure and inversely with contraction of the ar- 
terioles. The output varies inversely and the venous di- 
rectly with the resistance of the flow. This factor is 
made up of the resistance, positive or negative, offered to 
the entrance of blood into the right auricle, to which 
must be added the influence of the intrinsic contraction 
of the veins, their compression by variable external forces, 
as muscular pressure and mechanical stretching, and espe- 
cially by the influence of gravity. In the weak vascular 
system the blood column, in the upright position, settles 
in the splanchnic veins to such a degree as to lower ar- 
terial pressure; then when the recumbent position is as- 
sumed gravity no longer impedes the passage to the heart 
of this retarded blood, and arterial pressure is raised by 
the excess of blood added to the circulation." — Sewall. 

Pulse. — This is due to the distension of the artery by 
the pulse or blood wave. Pulse felt by the finger is due 
to the hardening of the wall by the increase of pressure. 
The sphygmogram shows the events in the pulse. The 
ascent is abrupt and unbroken, due to the discharge of 
blood from the heart, transmitted by the blood wave. 
The descent is more gradual, shows the predichrotic and 
dichrotic notches, and represents the diastole of the heart. 
The dichrotic wave is due to the wave from the valves, 
showing pressure diminished, more diminished and in- 
creased. 



CIRCULATION. 19 



A dichrotic notch is seen in tracings from normal 
persons. Dichrotic pulse is not a normal condition, and 
when present gives an exaggerated dichrotic notch in 
tracings. 

Dichrotic pulse is favored by short primary pulse 
wave as is usual in fever ; favored by reduced tension and 
short systole. Wall must possess normal elasticity. In 
fever dichrotism appears to be due to the elevation of 
temperature, which causes a greater distension of the ar- 
teries and quicker heart beats. It is said to be due to the 
undue elasticity of the blood vessels with relaxation of 
the arterioles, so that the blood first unduly distends the 
arteries, which then contract upon it, and thus produce 
the second wave from apex to pulse curve. 

The period of descent on curve denotes the time that 
the blood is flowing out of arteries into the capillaries. 

When there is a vascular spasm the flow is difficult 
and gradual. 

If there be vascular relaxation, the outflow is short. 

If the drop is sudden it is the so-called "empty ar- 
teries/' seen after hemorrhage or in cases of aortic re- 
gurgitation. 

With vascular relaxation the beat is more rapid. 

A very slow pulse in a majority of cases depends 
upon the high arterial tension from the vascular spasm, 
i. e., resistance to the flow of blood; more rarely due to 
the irritability of the vagus, produced by pressure or 
disease, or by drugs as digitalis. 

Pulse hard, with artery tense, means a heart beat 



20 APPIylED PHYSIOLOGY 

strong and volume great. It signifies an excited vaso 
motor center, causing contractions of the vessels, and 
that an over-acting heart is forcing blood into already 
tense vessels. The results of such a condition are : 

(a) True angina pectoris — heart becomes 
crippled, distended and paralyzed. 

(b) Vessels will burst in the weakest spot. 

(c) Spasm will give away. 

In young persons high arterial tension is as a rule 
due to some acute ailment, causing an excited circulation. 

In older persons, when not due to acute diseases, it 
is usually caused by one of the following conditions : 

(a) Atheroma of the vessels. 

(b) Renal disease of chronic interstitial type. 

(c) Hypertrophy of the heart. 

These imply, of course, that there is no history of 
recent stimulation. 

Low Tension. — This is due to feeble condition of the 
system or a general nervous debility. 

Anacrotic Pulse — Seen when : 

(a) The time of inflow is longer than elastic 
vibration, e. g., in dilatation and hyper- 
trophy of the heart (left ventricle). 

(b) The distension of arterial tube is diminished. 

(c) Blood stasis exists as a result of extreme 
retardation of blood stream, as in paralyzed 
limbs, not causing normal distension of ar- 
terial wall when ejected from the heart. 



CIRCULATION 21 



(d) An artery has been ligated in a peripheral 
segment. 

(e) Certain forms of aortic insufficiency exists. 

Murmurs in Body — Seen when: 

(a) Arterial tube is dilated at point where blood 
current is forcibly introduced from normal 
part of artery, e. g., aneurysm. 

(b) An organ presses on an artery — pressure 
murmurs, e. g.. uterus in pregnancy. 

Factors favoring murmurs in arteries — 

(a) Sufficient degree of delicacy and elasticity of 
vessel walls. 

(b) Low peripheral resistance. 

(c) Marked difference between pressure of fluid 
in stenotic portion and that of fluid in peri- 
pheral dilatation. 

(d) Large size of artery. 

Murmurs may be heard in normal pulsating arteries, 
viz., uterine or placental souffle; funic souffle; cere- 
bral murmurs (seen in one-half infants with thin 
skulls) ; over enlarged spleens ; thyroid thrill in 
exopthalmic goitre. 

Venous Hum — Heard above clavicle, generally in right 
side, 40 per cent of persons, may be continuous or 
synchrynous with diastole of the heart. 
Roaring or buzzing; hissing or singing. 
Generated within bulb of jugular vein. 



22 APPLIED PHYSIOLOGY 

Heard in normal persons by use of pressure or by 
turning head to opposite side and upwards. 

When no pressure is made cause is pathological. 

Cause — Whirling entrance of blood from narrow por- 
tion into dilated bulb below. 

Venous Pulse — In jugular it is a common phenomenon. 

When large it is pathological ; seen in affections of 
right heart. 

Supernumerary pulse may be seen, due to reflex ac- 
tion, as gastro-intestinal disturbances, etc. 

Water-Hammer Pulse. — (Corrigan's) — Due to increased 
volume of blood from the left ventricle, with rapidly 
rising and rapidly falling pulse. Seen in aortic re- 
gurgitation with hypertrophy. Small actual volume. 

Pulsus Paradoxus. — Under some conditions the pulse 
during inspiration may become extremely small or 
even extinguished ; pulsation returning with expira- 
tion. Cause not known; was thought to be due to 
pericardial adhesion along the great vessels. 

Various explanations — It is due to mechanical interfer- 
ence with the large veins and aorta; here the heart 
is unaffected. Obstructions in the air passages, caus- 
ing an increased negative intra-thoracic pressure, in- 
hibiting the heart action may be a cause. Lowered 
activity of the heart may produce the condition. 
The respiratory variation in quantity of blood pass- 
ing to the general circulation is sufficient to explain 
pulsus paradoxus. — Calvert. 



CIRCULATION. 23 



Said to be due to respiratory pump action on 
the heart and intra-thoracic vessels or to nervous 
impulses influencing the heart and vessels. 

Pulsus paradoxus seen in acute dyspnoea from 
pharyngeal obstruction is probably merely a pathologi- 
cal exaggeration of a physiological condition. This 
is explained by the effect of the negative pressure 
around the heart during inspiration. An inspiration 
first widens the pulmonary vessels and increases the 
lung reservoir capacity; but secondarily, by lessen- 
ing resistance it increases the rate of flow through 
the pulmonary vessels. This pump action is not the 
only factor in the production of respiratory pulse 
variations, as is shown by the fact that section of the 
vagus nerve does away with such variations. 

Pulsus Alterans — This is a condition characterized by 
beats irregular in force but regular in rhythm. 

Pulsus Differens — Due to alteration of the lumen of 
the aorta, chiefly caused by atheromatous changes. 
The two sides show a difference in volume and force. 
This condition is most frequently seen in aortic 
aneurysm, but may be present with an alteration of 
other vessels clue to aneurysm, tumors, fluid, etc. 

Angina Pectoris (so-called neuralgia of the heart) — 

Symptoms — Presumed to be a shutting off of the 
blood supply or a cardiac ischaemia, due to an 
arterio-sclerosis or a thrombosis of the coronary 
arteries. 

Pain — Many attempts have been made to explain 



24 APPLIED PHYSIOLOGY 

this symptom. It is fairly concluded that the 
sensory nerves of the heart, which are likely the 
depressor filaments of the vagus, are irritated by 
the deprivation of blood. Hare states that the 
pain depends upon vascular distension in the 
mediastinum, which is the result of a more or 
less vasodilatation and of a more or less general- 
ized peripheral vasoconstriction. The work done 
by the left ventricle and the integrity of the 
mitral valve are factors in the mediastinal dis- 
tension. 

Great Anxiety — This is due to the mental effect of 
feeling about the heart. When the sensory im- 
pulses about the heart reach the medulla, they 
are eventually returned in the vagus proper to 
the heart, which becomes inhibited. It may be 
so slowed that it actually feels as if the heart 
were not contracting, giving sensation of 
crammy, or like the heart was in a vise. 

Radiation of Pain — Due to the transfer of sensory 
impulses in the medulla to centers of the inter- 
costal nerves and brachial plexus. 

Heart Block — (Stokes-Adams disease) — 

Heart block may be either partial or complete. 

There are two kinds of partial block : 

(a) Organic, due to a lesion in the course of the 
bundle of His ; and 

(b) The failure of the ventricle to follow all 



CIRCULATION 25 



the impulses from the auricle, due to over- 
action of the vagus. 

The former type is always to be regarded as a 
forerunner of complete block. The second type can 
be differentiated from the first only by means of 
atropin, or some drug which paralyzes the vagus. 
It might be possible in favorable cases to feel an 
omission of the radial pulse or apex beat and see 
that a conspicuous venous pulsation continued with- 
out interruption. This could only be due to a block 
of that particular auricular impulse and would point 
to incipient heart block. — McCaskey. 

In addition to organic lesions, probably influ- 
ences exist which are very likely nervous in char- 
acter and affect the conductivity either through the 
vagus or indirectly by altering the auricular fre- 
quency. — Hay and Moore. 

"In complete heart block, produced by destruc- 
tion of the auriculo-ventricular bundle, the normal 
influence of the vagus over the auricles is preserved, 
whereas its influence over the ventricles is lost al- 
most entirely. Stimulation of the vagus will, in such 
cases, stop the auricles, but the ventricles will con- 
tinue to beat with practically unchanged rate. The 
prolonged stoppage of the ventricles, when the vagus 
is stimulated in normal animals, must be due to the 
fact that the vagus stops the auricles, and the ven- 
tricles therefore stop until their inherent rhythmicity 
develops to the point at which they begin to beat 
spontaneously. The vagus likewise does not act on 
the ventricles of man, since in cases of complete 
heart block atropin does not increase the ventricular 



26 APPLIED PHYSIOLOGY 

rate, although it exercises the usual accelerating ef- 
fect over the auricles. The accelerator nerves act 
directly on the auricles and ventricles. In the pres- 
ent state of our knowledge these changes in the rates 
of auricles and ventricles can be explained only on 
the assumption that they are caused by a simul- 
taneous diminution in the tone of the vagus and ac- 
celerator centers in the medulla. The syncopal at- 
tacks of Stokes-Adams disease might be caused, 
namely, by a sudden increase of the auricular rate 
while the block is partial." — Erlanger. 

Myocarditis — This disease may be either acute or chronic 
Acute myocarditis — 

(a) Generally part of the structure involved in 
an acute infection. 

(b) May be caused by any condition which will 
prevent normal muscular oxidation changes. 

Causes of symptoms — 

Pain — Due to involvment of the pericardium. 

Irregular heart action — Due to degenerative 
changes in the muscles. 

Septicaemic symptoms — Due to rupture of myo- 
cardial abscesses into the heart cavity and 
from thence into the blood. 

Chronic Myocarditis — Due to poisons, irritants, non- 
oxidation, etc. 

Symptoms — 

Slow, irregular heart action — Part of energy is 



CIRCULATION 27 



expended in overcoming the resistance of an 
unusual amount of fibrous tissue. 
Dyspnoea — Failure to pump the blood through 
the lungs. 

Murmurs — Due to associated endocarditis, or to 
imperfect valvular action, caused by de- 
generated condition of the musculature. 
These murmurs are generally of weak char- 
acter. 

Pericarditis — Likewise may be acute and chronic. 
Symptoms — 

Chill and fever point to infectious origin. 
Pain — (a) Irritation of nerve endings; friction 
rub. 

(b) Effusion is greater than absorption of 
lymphatics. 

Dyspnoea — Effusion prevents free relaxation of 
heart in diastole; hence amount of blood 
passing to lungs is decreased. 

Cyanosis — Due to same cause. 
Aphonia — Pressure on the recurrent laryngeal. 
Cough — Irritation of tracheal nerves by com- 
pression. 

Dysphagia — Due to pressure on esophagus. 

Rapid heart action — General infection; effort to 
compensate for extra work. 

Modified heart action — Due to removal of nor- 
mal tonic inhibition of the vagus. 



28 APPLIED PHYSIOLOGY 

Low arterial pressure — When this occurs it is 
due to the fact that the effusion presents an 
obstacle to the flow of blood into the heart, 
the pressure in the great veins rises against 
the continuous atmospheric pressure exerted 
upon the veins in the neck, etc. The right 
auricle receives less blood, hence less goes 
to the lungs. Then the left auricle receives 
less from the lungs and consequently there 
is less to be thrown into the aorta and blood 
pressure falls. 

High venous pressure — When much effusion, 
low arterial ; failure of heart to receive and 
discharge blood. May re-establish an equili- 
brium. 

In the production of the low arterial pressure more 
blood is gradually sent into the veins at each 
diastole of the heart than enters the aorta dur- 
ing the systole, hence in a short time the 
pressure rises considerably. 

Enlarged veins in neck — Failure of heart to 
pump blood through pulmonary circulation 
rapidly enough. 

Delirium and coma — Probably result from toxe- 
amia acting on brain. 

Systolic retraction of apex — Due to adhesions, 
chiefly in region of the base of the heart, pre- 
venting the normal movement of heart. 



CIRCULATION 29 



Endocarditis — Acute and chronic. 

Acute endocarditis — Seen in infectious diseases, etc. 

Symptoms — Febrile reaction — Part of general 
infection, or inflammation set up in the en- 
docardium. 

Increased pulse rate — Chiefly reflex, afferent 
nerves, being from, in and about the heart. 

Secondary symptoms — Due to lodgement of em- 
boli from the heart in brain, lungs, etc. 

Chronic endocarditis — By this term is meant a 
chronic valvular disease. 

Symptoms — These are due to failure of the 
blood to reach the respective organs with 
proper pressure and failure of the heart to 
take venous blood from these organs. In 
most instances we find a passive congestion. 
Each symptom can be easily explained by 
the blood pressure, i. e., failure to maintain 
the equilibrium between the arterial and 
venous pressures. As this is the disease 
where so much has been said in regard to 
treatment, let it be remembered, once and 
for all, that too much attention has been 
paid to the heart and not enough to the vari- 
ous parts of the body which regulate this 
equilibrium between the arteries and veins. 
More attention should be paid to the venous 
pressure. 

Symptoms of valve lesions may be seen where a 



30 APPLIED PHYSIOLOGY 

dilated heart has caused the separation of 
the valves at their base, permitting a regur- 
gitation. 

LESIONS OF CARDIAC VALVES. 

Compensation is the hypertrophy, i. e., in the size 
and strength of the heart to make up an insufficiency, or 
to overcome abnormal resistance. 

Loss of compensation — Causes : 

i — Increased damage to the valves. 

2 — Cardiac and arterial degeneration. 

3 — Intercurrent disease, e. g., pneumonia. 

4 — Undue physical exertion or nervous strain. 
Symptoms of loss of compensation : 

Cyanosis, anasarca, ascites, oedema of feet, etc., 
are clue to the lowered arterial pressure, in- 
creased venous pressure and slowing of the 
capillary current. 

Cardiac symptoms, as palpitation and cardiac 
distress, etc., are due to interference with 
the normal heart action. 

Cerebral symptoms — Due to cerebral congestion. 

Headache, flashes of heat and feeling of faintness 
on rising are due to sudden changes in ar- 
terial pressure. 

Pulmonary symptoms — Due to congestion of 
lung areas resulting from cardiac weakness. 
These are dyspnoea, cough, expectoration 
and haemoptysis. 



CIRCULATION. 31 



Dyspeptic symptoms — Due to congestion of the liver, 
stomach and intestines. 
Renal symptoms — Due to congestion. The 
urine is scanty, later it is albuminous, con- 
taining casts due to a resulting nephritis. 

Mitral Stenosis — 

This condition is generally associated with mitral 
insufficiency. 

Murmur — Heard at apex, on account of the position 
of the heart in chest. 

Time — Diastolic ; as it occurs during the last part of 
the diastole. It is frequently called praesystolic, 
due to the fact that at the onset of the auriculo- 
ventricular diastole blood flows moderately fast 
into the auricle, so that often no vibrations are 
caused by it to produce a murmur. The vibra- 
tions attain strength to produce the murmur in 
the latter part of the diastole. 

The murmur is not transmitted. 

Effect on the heart — The left auricle enlarges and 
loses power, hence blood accumulates in the 
lung. To overcome this obstruction the right 
ventricle hypertrophies. 

Sequence — Tricuspid regurgitation may occur, 
caused by dilatation of the right ventricle pre- 
venting closure of the tricuspid orifice. 

Mitral Regurgitation — 

Murmur — Heard at the apex. 



32 APPLIED PHYSIOLOGY 

Time systolic, caused by the blood, which during 
contraction of the ventricle passes through the 
auriculo-ventricular opening into the relatively 
wide auricle, producing vibrations of those parts 
which are concerned in it. 

Transmission is to the left axilla and angula of the 
scapula, explained by the direction of the regur- 
gitated blood and by the solid media. 

Effect on the heart — The left auricle enlarges and 
has less power; blood accumulates in the lungs 
and the right ventricle hypertrophies to over- 
come the resistance. 

Sequence — Tricuspid regurgitation may result, 
caused by dilatation of the right ventricle pre- 
venting perfect closure of the tricuspid orifice. 

Aortic Stenosis — 

This condition is rare alone; usually accompanies 
aortic regurgitation. 

Murmur — Heard at the right intercostal space. 

Time — Systolic, corresponding to the passage of 
blood through the stenotic valve. 

Transmission is upward into the carotids, following 
the line of direction of the blood stream. 

Effect on the heart — Hypertrophy of the left ven- 
tricle to overcome the obstruction at the valves. 

Absence of apex beat — Due to fact that in some 
cases as long as the heart acts vigorously to a 
certain degree', during closure of the valves in 
aortic stenosis, durinsf which normally the heart 



CIRCULATION. 33 



beat occurs, the pressure in the aorta is rela- 
tively low, and the semilunar valves are able to 
open at the first onset of the systole, and the 
ventricle empties itself from the beginning, 
hence there is no closing period and with it no 
apex beat. 

Pulse — Frequently pulsus tardus exists, due to rigid- 
ity of the artery associated with stenosis, also 
to the impeded influx of blood into the aorta. 

Sequence — Mitral regurgitation occurs because of 
dilatation of the left ventricle, which prevents 
the valves at the mitral orifice closing. 

Aortic Insufficiency — 

Murmur — Heard at the left margin of the sternum, 
at the junction of it with the second to the 
fourth costal cartilage. Heard in this area on 
account of the sound being transmitted down- 
ward with the reflux of blood. 

The sound may be praesystolic, as some time elapses 
after contraction of the heart until blood regur- 
gitates. 

Arching of praecordial area — Due to hypertrophy of 
the heart. 

Diffuse pulsation of chest wall and a "heaving" apex 
beat are due to the powerful action of the heart. 

Pulse — The pulsus altus et ceier, called Corrigan's 
water-hammer and collapsing are due to increase 
of the pulse wave with a sudden drop. 

Effect on the heart — Hypertrophy of the left ven- 



34 APPLIED PHYSIOLOGY 

tricle to overcome loss of blood returning from 
the aorta. 

Pulsating arteries and capillary pulse are due to sud- 
den alteration of force of the blood wave. (See 
forms of pulse). 

Sequence — Mitral regurgitation occurs due to dilata- 
tion of the left ventricle, preventing closure of 
the mitral orifice. 

Tricuspid Insufficiency — 

Murmur — Right sternal border toward its lower 
portion, about fourth or fifth interspace. Trans- 
mitted to the right, due to direction of current 
and heart structure. 

Time-systolic; corresponds to the regurgitation of 

blood in the right auricle and in the vena cava. 
Cyanosis and oedema — Due to great venous tension 

produced by the failure of right heart to receive 

the systemic blood. 
Venous pulse — Due to regurgitation of blood from 

the right ventricle into the large veins of the 

body. 

Arterio-Sclerosis (Atheroma) — 

Most of the symptoms are due to the non-elasticity 
of the vessel walls, and to consequent lack of 
nutrition. 

Symptoms. — Pulsus tardus — Due to increased work ; 
may be coincident with or precede the arterio- 
sclerosis. 



CIRCULATION 35 



Cardiac murmurs — 

(a) Valve changes. 

(b) Atheroma of aorta; a diastolic murmur 
when present, is due to the atheroma inde- 
pendently or extending to the aortic valves. 

Sequelae of arteriosclerosis — 

Apoplexy ; other general symptoms. 

Angina pectoris. 

Gangrene. 

Palpitation, arrhythmia, bradycardia. 

Intestinal cramps, etc. 

Arteriosclerosis affecting the renal arteries generally 
precedes or accompanies the nephritis. 

Arteriosclerosis of the general vessels gives impaired 
memory, headache, vertigo, etc. 

Arteriosclerosis may produce vaso-motor and trophic 
disturbances due to various degrees of vaso- 
dilatation. 

May have emphysema and bronchial catarrh, in 
which cases the vessels supplying these lung 
structures are generally affected secondarily to 
other parts of the general vascular system. 

Aneurysm — Generally due to atheroma. 

Many of the symptoms of this condition can be ac- 
counted for in manner like to that of the arteries. 

Aortic Aneurysm — 

Pain — Due to pressure upon the intercostal nerves 
or brachial plexus, likely to radiate along the 
course of these nerves. As the sac grows in- 



36 APPLIED PHYSIOLOGY 

ward, on account of less resistance and the tis- 
sues being less sensitive, the pain is not so 
marked, nor is it likely to radiate. 

Pain is influenced by the position of the body ; when 
it is so inclined that the sac makes pressure upon 
the nerves, it is consequently more severe. 

Dyspnoea — Most marked when the tumor is inter- 
nal. Due to pressure, causing irritation of the 
recurrent laryngeal nerve, when laryngeal spasm 
is likely to occur. 

Cough — Due to: 

(a) Pressure upon the vagus and recurrent 
laryngeal nerve. 

(b) Compression of the trachea and bronchus. 

(c) Pressure upon the lung, causing retained 
secretions or a destructive process. 

Hemoptysis — Blood may come from : 

(a) Granulations of the tracheal mucous mem- 
brane. 

(b) Bronchial congestion. 

(c) Destruction of the lung. 

(d) Destruction of the sac. 

Dilatation of superficial veins — Due to pressure upon 
the large veins. 

Pulsus differences — Due to alteration of the lumen of 
branches of the aorta, chiefly caused by athero- 
matous changes. The two sides show a differ- 
ence in volume and force. 






BLOOD 37 

Vomiting — Due to pressure upon the vagus. 
Tracheal tugging — Pressure upon the trachea. 
Changes in pupil — Pressure upon the sympathetic. 

In aneurysm', when the pulsations are seen, they ex- 
tend in all directions, while pulsations communicated to 
other tumors by vessels close by, appear to originate 
only from one side. 



CHAPTER II. 

BLOOD. 

Specific Gravity — 

Normally 1056-1059 in man; 1051-1055 in woman. 

Phasma, 1027; corpuscles, 1105. 

Density of blood mostly due to iron in corpuscles. 

Specific gravity shows corpuscular richness of re- 
spective tissue and haemoglobin equivalent of 
red blood corpuscles. 

Blood is like serum at times in puncture in perni- 
cious anemia, when the number of red blood 
corpuscles are markedly diminished and abso- 
lute amount of haemoglobin greatly diminished. 

Polycythemia gives a rise in density, etc. 

Specific gravity is increased in loss of fluids to the 
body. 

Decreased in dilution of the blood. 



38 APPLIED PHYSIOLOGY 

Form of corpuscles — 

Red — Circular, bi-concave, 1/3200 in. in diameter. No 
nucleus. 

White — More or less spherical, 1/3000-1/2400 in. in 

diameter. 

Polymorphous, polynuclear, neutrophils, about 
70%. 

Small, mononuclear, lymphocytes, 15-30%. 

Large, mononuclear, macrocytes, 4-10%. 

Eosinophiles, single or lobed, 1-10%. 
Platelets — Oval, round, irregular. 
Crenation — Corpuscles are shrunken with irregular 

surface. 

Poikilocytes — Changes in size and shape of red cor- 
puscles. 

Normoblast — Nucleated red corpuscles. 

Megaloblast — A large nucleated red corpuscle. 

Microblast — Small nucleated red corpuscle. 

Nucleated red blood corpuscles seen after severe 
hemorrhage, diseases of bone marrow, spleen 
and lymph glands. 

Alterations in size and form of red blood corpuscles 
seen in conditions producing changes in the 
blood as anemia, malaria, septic conditions, etc. 

Alterations in the size, shape and number of nuclei, 
in the white blood corpuscles, seen in anemias, 
syphilis, scurvy, intestinal diseases, and many 
chronic diseases. 



BLOOD 39 

Reaction of Blood — 

Normal reaction of blood is slightly alkaline. 

Alkalinity is due chiefly to sodium salts, held in solu- 
tion in the blood plasma. 

Alkalinity is decreased in health by exertion, due to 
formation of lactic acid. 

Physiological variations to excess are quickly re- 
moved by kidneys, etc. 

Acidity is probably neutralized by ammonia com- 
pounds formed from proteins. 

Alkalinity is decreased in — 

Anemia — Probably due to diminished number of 
red blood corpuscles. 

Uremia — Due to elimination of ammonia. 

Rheumatism — Due to formation of acids. 

High fever — Products of metabolism. 

Diabetes — Acid formation. 

Cholera — Loss of liquids, etc. 

Alkalinity increased in — 

Vomiting — May be due to HCL given off. 
Acute diseases, in early stages. 

Color of Blood — 

Normally scarlet in the arteries, and a dark, bluish- 
red in the veins. 

The red color is due to the oxy-haemoglobin in the 
red blood corpuscles. Pink color of lips, etc., 
due to blood. 



40 APPLIED PHYSIOLOGY 

Pale, waxy-white lips due to either few corpuscles, 

or less haemoglobin. 
Ghastly, blue lips are seen in asphyxia, heart lesions, 

etc. 

From these few remarks on the appearance of 
the lips it should be understood that the color of 
the blood in a part, and consequently the diagnostic 
value of the external appearance, may be due to : 

(a) The number of red corpuscles. 

(b) The amount of contained haemoglobin. 

(c) The condition of the vascular system, in- 
cluding the action of heart. 

(d) The normal appropriation of oxygen by the 
lungs and tissues. 

Asphyxia — 

Occurs when the body cannot obtain and appropriate 
a sufficient amount of oxygen. 

Blood becomes a dark purple, charged with retained 
C0 2 , which prevents coagulation, when this 
blood is shed. 

In drowning, there is an artificial hydraemia. Fluid- 
ity in part is due to inhibition of H 2 excretion 
and absorbtion of water. 

In poisoning, the blood suffers in the same manner 
in appearance, as in asphyxia, viz., the most 
common poisons, acids, alkalies, phenol, strych- 
nine, mercury, opium, etc. 

It is theoretical at the present time as to the causes 
of the blood changes in some of these poisons. 



BI,OOD 41 

Strychnine — Death is due to asphyxia, hence the 
change in the blood is quite apparent. 

Arsenic and metallic poisons — There is an alteration 
in the constitution of the blood, which prevents 
coagulation at death. 

Prussic acid, alcohol, opium, etc. — Cause of dark 
blood not known. 

Common conditions which are the direct cause of 
paleness : 

Lack of fresh air. 

Lack of proper amount of exercise. 

Metabolic disorders. 

Anemia (which includes lack of iron). 
Pinkish hue is seen in diabeter mellitus. 
Dark blue in dyspnoea. 
Dark green at times in H 2 S poisoning. 

Number of Corpuscles — 

Normally — Red — 5,000,000 in man, 4,500,000 in 
woman, in each cu. m. m. of blood; 4,000,000- 
6,000,000 considered within normal limits. Life 
of red corpuscles is given as 2-4 weeks. 

White — Average number in cu. m. m. is 8,000-10,000. 

Platelets — 150,000-500,000. 

Red — Changes in number of — 

Agents which increase the volume of blood 
plasma, consequently cause a decrease in 
the number of corpuscles in each cu. m. m. 



42 APPLIED PHYSIOLOGY 

Increased (polycythemia) in — 

Passage through cutaneous arterioles. 

Taking of solid food. 
. Loss of liquids from body. 
High altitude, increase only relative. 
Some anemias, as chlorosis. 
Recovery from severe anemias. 
Phosphorus poisoning. 
An apparent increase is seen in conditions which for 
any reason interfere with normal circulation, as 
tumors, cyanosis, bandages, etc. 

Decreased (oligocythemia) in — 

Hemorrhage. 

All forms of blood disease except chlorosis. 

All fevers and acute diseases. 

Wasting and chronic diseases. 
White Corpuscles, changes in number of — 

Physiologically increased in pregnancy, parturition, 

after eating, violent exercise, cold baths and 

moribund state. 

Leucocytosis is relative increase of all kinds. 

Pathologically increased in inflammatory diseases, 
toxic diseases, malignant diseases and leukemia. 

There is an absence of leucocytosis in malaria, La- 
Grippe, measles, Rotheln, mumps, cystitis and 
acute miliary tuberculosis. 

Decreased (leucopenia) in — 

Starvation, most infectious diseases where there 
is no leucocytosis, pernicious anemia, splenic 



BLOOD 43 

anemia at times and severe secondary hemorr- 
hages. 

It would be impossible to ascribe the particular 
cause of change in number of red or white corpuscles 
m each instance. The reader is referred first to the 
description of "formation of corpuscles." 

The alterations are in each instance an effort 
of nature to better nourish and protect the body. 
The recent advances in the subject of "immunity" 
will assist us very much in the study of the white 
corpuscles. To a certain extent, those conditions, 
like splenic and lymphatic anemias, involving those 
structures having to do with formation of white cor- 
puscles, will cause an increase in the number, as the 
parenchymatous structure is enlarged. 

On the other hand, as all red blood corpuscles 
are probably nucleated in the first steps in their 
formation in the marrow of bone, corresponding to 
the early embryonic forms, it is particularly with 
those diseases where the marrow is affected that we 
are likely to find nucleated red cells. 

Mono-leucocytosis — Increase in number of mono- 
nuclear white cells. 

Poly-leucocytosis (neutrophilia) — Increase in neutro- 
phils. 

The first is due to pressure and osmosis; metabolic 
changes. 

The second is due to phagocytic, bactericidal and 
chemotaxic powers. 



44 APPLIED PHYSIOLOGY 

Eosinophilia — Increase in number of eosinophiles. 

Myelcmia — Myelocytes in the blood stream, due to 
bone changes. 

Haemoglobin — 

Most important constituent of blood. 

Forms 90% of corpuscles. 

Function is to carry oxygen to tissues. 

Increased in high altitude ; quantitative, not quali- 
tative. In anemia, qualitative, not quantitative. 

For more Hb. to be in corpuscles, they must be 
larger. 

Decreased in lack of fresh air, anemia, lack of iron, 
haemolysis. 

Actual decrease of Hb. is a very common condition 
of blood. 

Quantity of Blood — 

Average amount of blood in the body is 1-13 to 1-25 
of its weight. 

Oligemia — Reduction in total volume of blood, 
plasma and corpuscles. It is applied to loss 
from hemorrhage. 

Plethora — Excess of the total volume of blood; may 
be transitory as after amputation of a limb. 

Serous plethora — Excess of the total liquid of the 
blocd. 

Hydraemia — Excess of the relative amount of liquid 
of blood. The physiological factors are inges- 



BIyOOD 45 

tion of liquids, vaso-motor dilatation, etc. These 
are transient. 

One-fourth to one-third of the total quantity of 
blood may be lost without great harm. 

It is possible to inject an amount of saline solution or 
blood equal to one-half or two-thirds of the orig- 
inal volume of blood without producing the slight- 
est discomfort to the animal or any permanent 
rise in its aortic blood pressure. 

The harm from shock is often greater than from the 
hemorrhage. Less shock under anesthetic. 

Transfusion — 

Blood of same species or genus may be directly trams- 
fused; in this the danger of coagulation is great. 

Defibrinated blood of the same species or genus may 
be transfused indirectly ; danger is that the fluid 
contains greater per cent of thrombin than nor- 
mal blood, also foreign matter and bacteria. 

Artificial serum — Physiological saline solution is 
very good. Indications for this are dangerous 
hemorrhage, C0 2 poisoning, etc. 

Hemorrhage — 

Symptoms — Countenance ghastly pale, pupils widely 
dilated, dyspnoea, mind confused, vomiting, ex- 
tremities icy cold, profuse cold clammy pres- 
piration, thirst intense, excessive restlessness, 
calls for air, paroxysms of swooning, pulse long 
absent from wrist, death. 



46 APPLIED PHYSIOLOGY 

In death from hemorrhage, we are mindful of 
the normal value of the quantity of blood as well as 
of the component parts. When we remember that 
with the heart we are often able to revive its action, 
after cessation of beats, by restoring the endocardiac 
pressure, by passing blood, etc., through its nutrient 
vessels, and many other similar phenomena, it can 
easily be seen how, when the heart has lost the nor- 
mal amount of blood to contract upon, it is unable to 
continue its action, and death takes place in a rapid 
hemorrhage long before the respective tissues of the 
body are suffering from lack of nourishment. 

The value of transfusion is likewise seen, in that 
it gives the heart liquid to increase the endocardiac 
pressure, fills the vessels, increases the rapidity of 
the circulation, thus making the diminished supply 
of haemoglobin of more value. The lagging cor- 
puscles are again started on their journey, and thus 
the body is sustained until a restoration of haemo- 
globin, etc., can take place. 

Hemorrhage is the escape of all constituents of 
the blood from the vessels (extravasation) into the 
tissues or upon a free surface. Hemorrhage may be 
due to rupture of heart or vessel-wall — per rhexin 
or per diabrosin; this form is seen in hemorrhage 
from the heart and arteries. 

Hemorrhage may be due to diapedesis, in which 
the red cells escape through the vessel-wall without 
the occurrence of a tear, this is seen in the veins and 
capillaries. 



BlyOOD 47 

Hemorrhage per rhexis is due to : 
Traumatism. 

Increase of intravascular pressure. 
Diseased condition of vessel-wall. 

Hemorrhage by diapedesis is due to : 

Increase of blood pressure in capillaries and 

veins. 
Increased permeability of vessel-wall. 

Metabloic Changes Caused by External Hemorrhage — 

(Gies). — 

Bile — Formation and flow of bile is markedly dim- 
inished. 

Alkalinity of blood — Diminished ; described as due to 
neutralization by an increased production of acid 
katabolic products. 

Quantity of blood — Normal volume soon restored 
after small hemorrhages, due to the lymph being 
hurried from the tissue spaces into the blood 
vessels. After excessive loss of blood restora- 
tion of volume may not take place for several 
days. 

Ash of blood — Shown that the proportion of ash from 
both blood and serum remain practically un- 
changed. 

Coagulation — A tendency to increase is seen after 
hemorrhage. 

Corpuscles — Erythrocytes are at once diminished in 
number, and the leucocytes are increased. 

Fibrin is increased. 



48 APPLIED PHYSIOLOGY 

Osmotic properties — Molecular concentration slight- 
ly diminishes at once, but soon rises to normal 
or above. 

Blood pressure — Sinks at first, soon returns to nor- 
mal in non-fatal cases, by reason of vasomotor 
accommodations and increased ingress of lymph. 

Proteins — The relative protein content of remaining 
blood is immediately decreased after hemorrhage, 
due mainly to loss of corpuscles and influx 
of lymph. Content of corpuscles, albumins, glo- 
bulins, and fibrinogen soon begin to rise, rela- 
tively and absolutely. 

Solids — Decrease for a time after hemorrhage. 

Specific gravity — Immediately decreases. 

Sugar — Said to be an increased content. 

Water — Invariably increases. 

Body temperature — At first rises, then falls a degree 
or two below normal and soon returns to normal. 

Body weight — Said to increase after moderate bleed- 
ing at frequent intervals. 

Degeneration, fatty — Has been seen repeatedlv after 
hemorrhage. 

Digestion — Normal secretion and activity of gastric 
juice diminished. 

Heart — Generally increased after non-fatal hemor- 
rhage. Moderate loss quickens, excessive loss 
slows. 

Lymph — Flow increased. 



BL,OOD 49 

Katabolism — Protein katabolism quickened. Fat 
katabolism is diminished. Nothing known in re- 
gard to carbohydrate katabolism. 

Coagulation of Blood — 

Normally coagulation is due to presence of fibrino- 
gen and calcium salts in the plasma, and the 
proenzyme in the white blood corpuscles and 
platelets. The present view of coagulation of 
the blood is : The ferment (enzyme or throm- 
bin) which changes fibrinogen into fibrin, etc., 
is formed by the action of thrombokinase, an ac- 
tivating substance obtained from the leucocytes 
(can be obtained from various tissues), on the 
proenzyme — thrombogen — with the assistance of 
the calcium salts. Thrombogen is derived chief- 
ly from the blood platelets. 

Coagulation is hastened by — 
Temperature above normal. 
Contact with foreign bodies. 
Agitation. 

Addition of calcium salts. 
Presence of oxygen. 
Ferments. 

Coagulation is retarded by — 
Low temperature. 
Presence of carbon dioxide. 
Injection of peptones, leech extract, etc. 

Hyperinosis is an increase in the amount of fibrin 
network. It is suggested that hyperinosis is an 
indication of the individual's resisting power. 



50 APPIylED PHYSIOLOGY 

Coagulation is increased in — 

Acute inflammatory diseases. (All febrile states 

do not imply fibrin increase, for none is seen in 

fevers of grave cases of pernicious anemia and 

chlorosis). 

Inflammations of mucous membrane and skin. 

Febrile stages of chronic suppurations. 
Hyperinosis is generally associated with leucocytosis. 

Although fibrinogen and the calcium salts are 
present in the blood, coagulation does not take place 
normally during life, chiefly because the ferment is 
not in state to act. 

In certain diseased conditions large quantities 
of blood may pass out into the tissues, as into the 
pericardium, lungs etc., and coagulation take place. 
Here the ferment is present on account of the death 
of the white blood cells, which contains the pro- 
enzyme. Certain other factors besides the integrity 
of the white cells and the platelets no doubt exist, 
but are not known. 

After the death of an individual the blood in 
the heart and great vessels sooner or later coagulates, 
and there arise those formations which are known 
as post-mortem clots. Besides death of the white 
corpuscles, other chemical changes take place, which 
no doubt play an important part in the formation 
of the clots. 

Under certain conditions there may be formed in 
the heart or blood vessels during life firm deposits, 



BLOOD 51 

which are similar to clots formed after death. These 
are known as thrombi. 

Thrombi are divided into red, white and mixed. 

Red thrombi are formed under such conditions 
as the complete stoppage of the circulation 
or a marked slowing of the same, and com- 
prises the total mass of red cells. 

White thrombi, as well as the mixed, arise in the 
flowing blood and consist of masses of yel- 
lowish color, or of the various shades of red, 
or of alternating layers of red and white. 

The cause of the formation of red thrombi is to 
be found either in the increase in the production of 
fibrin-ferment, or fibrinogen substances, or in a dim- 
inution of the power possessed by the normal vessel- 
wall of inhibiting coagulation. 

The causes of formation of white and mixed 
thrombi are chiefly: 

(a) Changes in the intima of the heart and the 
vessels. 

(b) Diseases of the vascular apparatus, which 
lead to a general or local slowing of the 
blood stream. 

Thrombosis is due to two causes : 

(a) Disturbances of the circulation. 

(b) Local changes in the vessel-walls. 

Plasma — Fluid portion of the blood. 

The fluid portion of plasma is increased by anemia, 



52 ? :ft*™, APPLIED PHYSIOLOGY 

dropsy, anuria, ingestion of liquids, transfusion 
of salines. 

The fluid portion of plasma is decreased by loss of 
liquids to body, as in perspiration, effusions, 
polyuria, etc. 

Formation of Corpuscles — 

Red — Karyiokinesis of erythroblasts, chiefly in the 
red marrow of the bone. 

White — Lymph glands and the red marrow of bone. 

Destruction of Corpuscles- 
Red — Destroyed in liver and spleen. Part of Hb. is 

lost in pigments of bile. 
White — Destroyed in blood and lymph by simple 

disintegration. 

Function of Blood Corpuscles — 

Red — To carry oxygen. 

White — Carry solid particles from one organ to an- 
other. 

Repair tissue with fibrin. 
Surround foreign bodies and protect tissue. 
Phagocytic action. 

Chemiotaxis chemical and bacteriacidal products. 
Form opsonins. 
Form antitoxins, etc. 

The white are very important in natural immunity. 

Lymph Formation — 

Lymph is filtered blood. 

Equals from two to three times the amount of blood. 



BLOOD 53 

Chyle is lymph in the lacteals, and contains a high 
proportion of fats. 

Lymph not only carries off the waste products, and 
by virtue of the lymph glands, which act as i-e- 
pair shops, protect the organism, J)ut it directly 
nourishes the tissues. 

After the blood is brought to a part by the capillaries 
it is necessary that the albuminous material as 
well as fats and sugars be brought directly in 
close connection with the individual cells, 
whether for their own nourishment or for 
changes as are produced by glandular activity. 
This communication can only take place when 
the blood leaves the capillaries, which it does, 
and exists as lymph. 

It carries to the tissues these substances for their 
nourishment and places the blood in such a rela- 
tion to the cells, as in kidney, liver, salivary 
glands, etc., that the gland cell can select those 
substances needed for the various secretions and 
excretions. 

The chief sources of the lymph vessels are: 
Perivascular lymph spaces. 
Serous cavities. 
Receptaculum chyli. 

The formation of lymph as well as its circulation in 
the lymphatics is due to and influenced by alter- 
ations in: Vital cell action, filtration, diffusion, 
osmosis, muscular activity, blood pressure, res- 
piration, etc. 



54 APPLIED PHYSIOLOGY 

Oedema — 

Generally known as dropsy ; various terms are ap- 
plied to part affected. 

Oedema covers all those conditions where there is 
an abnormal accumulation in any part of the 
body of an albuminous liquid, resembling in its 
essential properties normal lymph. 

It is the generally accepted view now that oedema is 
simply an abnormal increase of lymph. 

Factors causing oedema (Meltzer) — 

(a) Chemic changes which lead to an increase 
of the osmotic pressure, or an increase in the 
water-attracting power of the tissues. 

(b) An increase in the difference between tntra- 
capillary and extracapillary pressure, by 
which the normal transudation of serum into 
the tissue spaces is increased. 

(c) An increase in the permeability of the en- 
dothelial wall of the blood capillaries in the 
oedematous parts. 

(d) An impairment of the mechanism of absorp- 
tion of tissue lymph. 

We might conclude by summing up the various con- 
ditions affecting oedema formation and say that 
it depends in some way upon : 

Condition of vessel wall. 
Composition of blood. 
Blood pressure. 
Rapidity of the flow of blood. 



BLOOD 55 

Salts— 

As mentioned, the various salts essential to the 

economy of the body are held in solution in the 
plasma and, consequently, circulate freely. Some of 
these are important in that they are combined, as the 
sodium salts, with the carbon dioxide, which is car- 
ried from the tissues to the lungs, the carbon dioxide 
being given off before reaching same by a neutraliza- 
tion, probably by acid substances formed either from 
protein substances in the tissues or formed either from 
blood corpuscles. 

Other salts may unite and form a chemical com- 
bination with the various protein substances. 

The salts are taken into the body chiefly with 
the foods. The great importance of various salts is 
easily apparent ; probably the function of greatest im- 
portance as far as can be learned is that of the role 
played in osmosis. This important physical process 
is of vital consequence in the circulation of the vari- 
ous liquids, formation of various secretions, etc. 
Again we see the necessity of the phosphates in the 
formation of bone ; chlorine in HCL ; iron in red 
blood corpuscles, and many other instances. An al- 
teration in the quantity of salts taken in and dis- 
charged from the body may cause many grave dis- 
orders. 

The cause of the changes in amounts of these is 
frequently not known. 

Some of the most common diseases where a 
variation exists are: 



56 APPLIED PHYSIOLOGY 

Chlorides — Diminished in febrile diseases. 

Phosphates — Diminishes in gout, Bright's dis- 
ease, and most acute diseases. 

Sulphates — Increased in meat diet, active exer- 
cise, meningitis and rheumatism. 

Calcium salts — Increased in gout; diminished in 
haemophilia. 

Extractives of Blood — 

Dextrose — An increased amount in the blood, called 
glycaemia, is seen in diabetes, and at times in 
carcinoma. 

This sugar, which is a normal constituent of the 
blood and which is the chief source of heat and en- 
ergy, may increase in amount in diabetes and be ex- 
creted by the kidneys. 

The destruction of sugar in the body is due to 
two processes, decomposition and oxidation. The 
decomposition occurring in the protoplasm of the 
muscle fibers, while possibly the oxidation of the de- 
composition products occurs in the other tissue ele- 
ments. — (Bunge). It is quite likely that in the light 
of recent investigations the location of the processes 
named are not as stated by Bunge, but that much of 
oxidation takes place in the blood itself. 

For these processes the formation of glycolytic 
and oxidation ferments is essential. In the forma- 
tion of these ferments the pancreas is given an im- 
portant place. We know that many other organs, as 
well as muscle, etc., furnish many ferments, which 



BIyOOD 57 

either alone or in combination with those of the 
pancreas assist in the processes. 

Fats- 
Fat in the blood is called lipaemia. A physiological 
increase is seen in: 

A diet rich in fats. 
Breast-fed infants. 
Pregnant women. 

Pathologically, an increase is not distinctive of any 
organ. 

Blood Pigments — 

Melanaemie-pigment (melanin) is seen in malaria, re- 
lapsing fever, malanotic sarcoma, Addison's dis- 
ease. 

Due to blood changes. 

Urea — 

Increased in meat diet and febrile conditions. 

Decreased when metabolism is retarded; in struc- 
tural diseases of the liver. 

Within certain limits the amount of urea given 
off in the urine depends upon the amount of protein 
food taken. As the liver is the chief seat of urea 
formation, it is easily seen how disease of this organ 
can affect the amount in the blood. See diseases of 
the liver. 

Purin Bodies — 

Increased in meat diet ; heart and lung diseases ; any 



58 APPLIED PHYSIOLOGY 

condition which can lessen the carrying power 
of the blood. 

Decreased when urea is decreased. 

ANEMIA. 

This condition may be primary or secondary. Prim- 
ary anemia being a condition in which the blood changes 
are such that they constitute a disease in themselves ; the 
symptoms being caused by the blood changes. Sec- 
ondary anemia is the result or a part of some other dis- 
ease. 

Other things being equal, the symptoms resulting 
from a diminution in the number of corpuscles, or the 
lack of haemoglobin, are the same regardless of the cause. 
A slowing of the blood stream in a part will produce a 
cyanosis even though that be the only part of the body 
affected. 

A general cyanosis, where the entire body suffers 
from the lack of oxygen, is due to diseases causing a 
non-aeration of the blood, viz., cardiac insufficiency, em^ 
physema, anemia, asphyxia, etc. 

A local cyanosis may be due to tumors, hemiphlegia, 
etc. 

Secondary Anemia — 

Causes — Infective or febrile diseases. 
Malignant diseases. 
Chronic suppurative nephritis. 
Cirrhosis of liver. 
Dysentery. 



BL,OOD 59 

Bad hygiene, pregnancy and lactation. 
Intestinal paracites. 
Poisons, e. g., lead and arsenic. 
In malaria the red cells are actually destroyed 
by the plasmodium. 

Primary or Essential Anemia — 

This condition is due to either a lack of forma- 
tion of blood corpuscles, or to their too rapid de- 
struction. The cause of the various forms of primary 
anemia is not known. As they are all characterized 
by changes in the number of corpuscles and to a 
less extent by the amount of contained haemoglobin, 
we would expect to find the organs and tissues con- 
cerned in the formation of these bodies at fault ; 
this can very frequently be demonstrated, in some 
forms of anemia, they are always abnormal. 

There is reason for believing that the bone mar- 
row is the chief seat of formation of the red cells in 
the embryo ; the spleen and the lymphatic glands as 
the seat of formation of the white cells. 

In later embryonic life, the number of nucleated 
red cells decreases and the non-nucleated ones in- 
crease, until at birth the nucleated red cells are not 
seen in the blood. As several forms of anemia pre- 
sent the embryonic nucleated red cells, we must 
think that the structures, active before birth, have 
again assumed charge, or rather, that structures 
which have taken up the post embryonic duties have 
failed to do their work. An organ like the thymus, 



60 APPLIED PHYSIOLOGY 

certainly concerned during early life in formation 
of blood cells, may forget to atrophy and disturb the 
general correlation of tissues concerned in the man- 
ufacture and destruction of the blood cells. 

It is thought that the post embryonic non- 
nucleated red cells are formed either by the nucleated 
ones dropping the nuclei, or that they are formed 
from a nucleus which is extruded. Even in adult life 
many of the red cells, if not all, may be first de- 
veloped in bone marrow with a nucleus, which disap- 
pears before reaching the blood stream. There is no 
evidence of red cells originating from leucocytes. 

Chlorosis — 

Erythrocytes generally somewhat decreased in num- 
ber; may be increased. 
Amount of haemoglobin much diminished. 
Specific gravity more or less diminished. 
Alkalinity generally normal. 
Coagulation generally rapid. 
Leucocytes but little changed. 

This disease affects only females. As there is no 
sign of cell destruction, the cause interferes with the 
synthesis of the haemoglobin. 

Symptoms — Patient often plump — Due to less oxida- 
tion of tissue. Deposits of fat. 

Pallor — Due to lack of oxyhaemoglobin. 

Weakness and shortness of breath — Less oxygen to 

the tissues. 
Cardiac murmurs — Probably due to blood changes. 



BLOOD 61 

Vertigo and palpitation of heart — Less oxygen to 

brain and body at large. 
Oedema of ankles — Blood changes. 

Pernicious Anemia — 

Haemoglobin markedly decreased. 

Leucocytes decreased, decided leucopenia. 

Nucleated red cells present. 

Coagulation slow; alkalinity and specific gravity, 

low. 
Number of red cells very much decreased. 
Disease due to a hemolysis; much pigment being 

found in liver, etc. 
Excessive fatty changes, due to lessened oxidation 

changes. 

Symptoms — Languor, debility, mental hebetude, etc., 
due to lack of oxygen. 

Blanching of mucous membranes — same cause. 
Jaundice probably due to blood destruction, so-called 

hematogenous. 
Gastric and intestinal disorders — lack of nutrition. 

Leukemia — May be spleno-medullary and lymphatic. 

Coagulation variable. 

Alkalinity and specific gravity decreased. 
Haemoglobin diminished. 

Red cells decreased; generally some nucleated red 
cells. 

Leucocytes markedly increased. 



62 APPLIED PHYSIOLOGY 

These conditions hold true for both forms of the 
disease. 

The spleen and lymphatic glands are enlarged. 
Changes take place in the bone marrow. 

Symptoms — Those due to other forms of severe ane- 
mia present; much the same sause. 

Great emaciation — Due to lack of nutrition. 

Hemorrhage from nose, etc. — Due to blood and ves- 
sel changes. 

Special symptoms as ascites, etc. — Due to enlarged 
spleen. 

Hodgkin's Disease — (Pseudo-leukemia) — 

Haemoglobin, later somewhat diminished. 

Red cells, later, decreased, with some nucleated. 

Leucocytes, normal or increased. Variation in some 
forms of the white cells seen. 

Spleen and the lymph glands enlarged; spleen not 
markedly. 

Symptoms of general anemia, pallor, dyspnoea, weak- 
ness and palpitation of the heart. 

Pressure symptoms — Dyspnoea, bronchial glands. 
Effusions, pleural or abdominal glands. 

Pain, pressure of glands upon nerves. 
General effects of anemia upon the body : 

(a) The respiratory center is affected. Normal- 
ly the oxygen in the blood is sufficient. In 
anemia, less oxygen in entire blood, scarcely 
enough for the patient at rest. Much short- 
ness of breath during exertion. 



BI^OOD 63 

(b) Fatty changes. In chlorosis, the amount of 
fat subcutaneously is quite considerable. 
The "tabby cat" heart in pernicious anemia 
is caused by deficient nutrition and less 
oxidation. 

(c) Epileptiform convulsions are associated with 
anemia of the brain. 

(d) Digestive disturbances, small amounts of 
oedema, etc., are associated with lack of 
nutrition. 

(e) Hemorrhage in severe anemia is probably 
due to fatty changes in the vessel walls. — 
(Lazarus-Barlow) . 



64 APPLIED PHYSIOLOGY 



CHAPTER III. 

RESPIRATION. 

Respiration is essentially characteristic of all living 



things. 



All living things, except perhaps anaerobic organ- 
isms, require oxygen for their vital processes. The uni- 
versal end product is carbon dioxide. 

External respiration — the gaseous exchange, which 
takes place between the blood in the pulmonary capil- 
laries and the air in the alveoli. 

Internal respiration — the gaseous exchange, which 
takes place between the blood and the tissues. The es- 
sential process of respiration, which is seen in the inter- 
nal interchanges, consists in the action of the oxygen 
after it is absorbed into the tissues, i. e., the part taken 
in metabolism. This process is a part of nutrition. The 
hypothesis formulated by Hoppe-Seyler is, that there 
occurs in the cell a fermentative decomposition of some 
substance analogous in all respects to the fermentative 
decomposition of calcium formate by many bacteria. By 
the fermentation nascent hydrogen is set free; the nas- 
cent hydrogen keeps the protoplasm in its reduced state ; 
it combines with one atom of the oxygen of the air to 
form water and sets free the other atom as nascent 
oxygen, which thus causes the intense oxidations of pro- 
toplasm. 

The explanation as set forth by Mathews is : "The 
real respiration of all forms of protoplasm, both aerobic 



RESPIRATION 65 



and anaerobic, is brought about not by the oxygen of the 
air, but by that of water. The hydrogen set free from 
the water combines with other elements of the pro- 
toplasm, thus keeping it reduced; it also combines with 
the oxygen of the air if this is present to form water, and 
in the absence of oxygen it may escape as free hydrogen. 
The only difference between anaerobic and aerobic res- 
piration is that the anaerobic protoplasm is so powerful 
a reducing agent that it is able to drive hydrogen out of 
the water, thus oxidizing itself without the aid of atmos- 
pheric oxygen to act as a depolarizer. * * * Pro- 
toplasmic respiration, therefore, is in reality not the con- 
sumption of gaseous oxygen and the liberation of carbon 
dioxide as ordinarily stated. We now know that the 
production of carbondioxide stands in no direct casual 
relation to the consumption of oxygen. Respiration is 
in fact the dissociation of water with the liberation of 
hydrogen." 

While the above is a very interesting hypothesis, it 
will require more experimental work before we are will- 
ing to lay aside much of the present teaching in regard 
to the gaseous interchange in the tissues. 

Organs of External Respiration — 

Lungs and upper air passages. 

Pleurae (essentially cavities containing an empty 
space. 

Muscles of inspiration and expiration. 

Nerves — Vagus, sympathetic, intercostals, phrenic, etc. 

Respiratory centers in medulla; subsidiary centers 
in cord. 



66 APPLIED PHYSIOLOGY 

Pulmonary blood vessels. 

Any condition which will in any way alter the 
normal action of any of the above structures will 
produce a change in the external respiration and 
indirectly affect the internal interchange. Still more 
indirectly will it affect the metabolism of body and 
the various functions performed 

Thus it matters not whether the disturbance be 
with the heart which fails to maintain the circula- 
tion through the lungs, with the air passages not per- 
mitting sufficient amount of air to enter the air-sacs, 
or a paralysis of a phrenic nerve inhibiting the action 
of the diaphragm, the gaseous exchange is interfered 
with in each instance, the effect depending upon the 
nature and severity of the lesions. 

Respiratory movements, or manner of breathing 
is divided into eupnea and dyspnea. 

Eupnea — 

In this, the chief point of distinction is that expira- 
tion is entirely passive. The term implies easy 
breathing. 

Inspiration occurs alone with the diaphragm or with 
the action of the levatores costarum and external 
intercostals. The ribs return at the end of in- 
spiration by physical forces, due to elasticity of 
the abdominal wall, elasticity of expanded lungs 
and the weight and torsion of the ribs. 

Quiet breathing is mainly diaphragmatic or ab- 
dominal. 



RESPIRATION 67 

We speak of the types of breathing as either costal 
or abdominal, implying that these respective 
parts are seen to act the more strongly. 

Costal breathing — In this the elevation of the ribs 
is the noticeable factor in inspiration. 

Abdominal breathing — The movements of the ab- 
domen, due to contraction of diaphragm, is the 
only or chief factor in inspiration. 

Natural type — Shows the movement fairly well bal- 
anced, abdominal in excess. 

Dyspnoea — 

Expiration is difficult and forced. Extra muscles are 

called into action. 
When respiration is dyspnoeic it is distinctly of the 

costal type. 
The relation of inspiration to expiration is :: 6:7 

or :: 3:4. 

Vital Capacity of Lungs — 

The importance of knowing the amount of air space 
within the air-sacs and air passages is quite evi- 
dent in many conditions where the amount of air 
taken in and given off seems to be much dim- 
inished. In these conditions the spirometer is of 
value, and will best show the tidal air, which 
would be normally 500 c. c, the reserve air nor- 
mally 1,500 to 1,800 c. c, and vital capacity nor- 
mally 3,500 to 4,000 c. c. 

Residual air — Amount of air in lungs, after forced 
expiration, 800 to 1,600 c. c. 



68 APPLIED PHYSIOLOGY 

Stationary air — Normal amount in lungs after ordi- 
nary expiration, 2,500 c. c. 

Minimal air — Small amount of air in alveoli after 
collapse of lung, due to collapse of small bron- 
chioles. This explains why the lungs float after 
excision. Called "lights" by the butchers. 

In the lungs in the living body, air caught in the 
alveoli may be completely absorbed. 

Artificial Respiration — 

This is employed whenever the normal movements of 
respiration are seriously interfered with. Most 
common conditions are failure of respiration dur- 
ing an anaesthetic, suffocation from drowning, 
inhalation of gases, etc. 

The purpose is to aid the emptying and filling of the 
lungs; the movements are made to correspond 
as nearly as possible in time and effect to that of 
normal breathing. 

The methods of particular value are : 

Marshall Hall method — Place the subject face 
down : roll body from this to lateral position, making 
some pressure upon the back in the prone position. 

Sylvester method (very frequently used) — Raise 
the arms above the head, bring them down against 
the sides of chest so as to compress the latter. 

Howard method — Compress the lower part of 
chest while the subject is in the supine position. 

Schaeffer method — This requires less labor and 
is not so injurious to the patient. Place the sub- 



RESPIRATION 69 

ject in the prone position, preferably on the ground, 
having a thick folded garment under the chest and 
epigastrium. The operator puts himself athwart or 
at the side of the subject, facing his head, and places 
his hands upon each side of the lower part of the 
lowest ribs. Slowly throw the weight of the body 
forward to bear upon the arms, thus pressing upon 
thorax of subject and force air out of the lungs. 
Gradually relax pressure by bringing body to more 
erect position without moving the hands. Repeat twelve 
to fifteen times per minute. This method is of 
greatest value in resuscitation from drowning. A 
half hour or more may be required. 

Various Pressures Affecting Respiration — 

Atmospheric pressure — This equals 760 m. m. of mer- 
cury, or about 15 pounds to the square inch. 
This pressure is exerted upon the outside of the 
chest wall, upon the great vessels entering chest, 
particularly the abdominal vessels and those in 
the neck. It is also the pressure which is ex- 
erted through the upper air passages. 

Intrathoracic pressure — The pressure in the thoracic 
cavity outside of the lungs. It is the pressure 
exerted upon the heart, and the great vessels in 
the chest. 

Intrapulmonic pressure — The pressure in the interior 
of the lungs. During inspiration, intrapulmonic 
pressure falls below the atmospheric. If the air 
passages are obstructed as in asthma, oedema of 
glottis or a cold in the head, there is a fall of 



70 APPLIED PHYSIOLOGY 

pressure in the lung during inspiration. When 
the glottis is closed, inspiration and expiration 
gives greater rise and fall. 

In coughing — Expiration is made with closed glottis, 
and there is a rise of pressure. During inspir- 
ation the conditions favor filling of the heart. 
There is increased blood flow (but less pressure) 
in the veins. The heart beat is increased in force 
and rate. The pulse is quickened. An increased 
amount of blood is sent from the left ventricle 
and the pressure in the arteries is raised. Dur- 
ing expiration conditions are such that the ven- 
ous pressure is raised. Hence, expiration pro- 
duces swelling of the veins in the neck, face, etc., 
and blue skin, and we see the evidence in epis- 
taxis and congestion ; in whooping cough, may 
have ecchymosis. In the forced expiration with 
closed glottis, as in cough, or in straining move- 
ments, as in parturition, the intrathoracic pres- 
sure rises with the intrapulmonary. 

Emphysema results from the increased intrathoracic 
pressure, the least supported, or weak parts, giv- 
ing first. 

Intrathoracic pressure is normally always less than 
one atmosphere, i. e., it is negative. 

The greater the lung is put upon the stretch, the 
greater is the negative condition of the chest. 

After most forcible expiration, when the air passages 
are open, intrathoracic pressure is still negative 
by a small amount. 



RESPIRATION. 71 



Forcible inspiration gives an increase of negative 
pressure in the thorax, whether the glottis be 
open or not. 

Pneumothorax — Air in the pleural cavity. 
Due to: 

(a) Injuries of chest wall, as fractured ribs. 

(b) Rupture in emphysema. 

(c) Rupture of an abcess. 

(d) Rupture of a tubercular nodule. 

(e) Penetrating wounds, etc. 

If the opening be kept patent, the lung will collapse ; 
the other being displaced. 

If the opening closes, the air may be completely ab- 
sorbed. 

In pulmonary tuberculosis, pneumothorax is most 
often associated with water, liquid effusion, 
called hydropneumothorax. 

Physiological Variations in Pressure — 

In swallowing, atmospheric pressure exists in the 
cervical oesophagus and less in the thoracic 
oesophagus ; thus air pressure becomes a factor 
in deglutition, supplementing the peristaltic con- 
traction of the oesophagus. 

Relation of Respiration to Heart Action — 

Atmospheric pressure is exerted upon the veins in 
the neck, and externally upon the vena cava in 
the abdomen, while in both cases the pressure in 



72 APPLIED PHYSIOLOGY 

the thorax upon the extensions of these vessels 
is less. 

At each inspiration, therefore, the blood is rapidly 
forced from these veins into the heart. 

Nervous Mechanism for Respiration — 

Respiratory centers are probably essentially auto- 
matic, although it may be proved that to a cer- 
tain extent respiration is in reality a reflex condi- 
tion. 

Respiratory centers are located in the medulla. 

Reflex stimulation of the centers may take place in 
stimulation of the cutaneous nerves, as by cold 
water; by stimulation of certain sensory nerves, 
which may either stimulate or inhibit respira- 
tion; through emotional states; through stimu- 
lation of nerves of sight, hearing etc. 

The sensory fibers are in the vagus to the lungs ; 
they maintain the rhythm. The rhythm is regu- 
lated by the condition of the air in the alveoli. 
Directly the rhythm may be altered by the con- 
dition of the blood flowing through the medulla, 
the change depending upon the proper aeration 
of the blood. 

Stimulation of the superior laryngeal branch, which 
supplies the mucous membrance of the larynx, 
inhibits respiration, and is protective in that it 
guards the lungs from gases, as HCL, CL, NH,, 
etc. At the same time the glottis is closed, re- 



RESPIRATION 73 

fiexly. Even the bronchi may contract by reflex 
action and protect the lungs. 
Irritating gases or foreign bodies, entering the larynx 
may lead to cough reflex, which is also protec- 
tive. 

We may consider that expiratory centers exist as 
groups of cells connected with expiratory 
muscles by definite paths, and which are capable 
of being stimulated in one of at least four gen- 
eral ways: 

I — Special reflexes — cough. 

2 — Voluntary control from the cerebrum — as in 
straining. 

3 — By stimulation, through different fibers in 
skin, especially pain fibers. 

4 — By action of venosity of the blood. 

Respiratory centers properly means the inspiratory 
centers. 

Possible views of stimulation of respiratory centers 

by blood in medulla : 

I — Normal stimulation is lack of oxygen. 

2 — Normal stimulation is increase of carbon 
dioxide. 

3 — The two above may co-operate. 

Dyspnoea implies an increase of force or rate of 
breathing. 

Hypernoea — Refers to the excessive breathing as 
initial stage of dyspnoea. 



74 APPUED PHYSIOLOGY 

Apnoea — Means no breathing. 

In medical literature, often wrongly used to express 
suffocation. 

It is due to lack of stimulation of respiratory centers. 
It is brought about by rapid and prolonged ventila- 
tion of lungs. 

Caused by: 

Removal of carbon dioxide from the blood. 
Rhythmical inhibition of respiratory centers 
through the vagus endings in the lungs. 

Asphyxia — Shows the following stages : 

Suffocation,, convulsions, calm due to exhaustion of 
respiratory centers, long-drawn inspiration, 
quietness and death. It is due to a lack of oxygen. 

Muscular work increases the rate and amplitude of 
respiratory movements, probably due to certain 
substances produced in the muscles, which are 
thrown into the blood. 

Effect of an Increased Amount of Oxygen — 

All living things are killed when the oxygen pres- 
sure is high, from 300-400 per cent. Warm blood- 
ed animals die with convulsions when three at- 
mospheres of pure oxygen, or fifteen atmos- 
pheres of air is reached. A pressure of two at- 
mospheres of air (40%) shows no injurious 
effect. 

Effect of a Diminished Amount of Oxygen — 

No bad results are seen until the oxygen reaches 



RESPIRATION 75 

10%. At or below this amount the haemoglobin 

of the blood cannot take up oxygen. At 10% 
respiration becomes deeper, more frequent and 

lips become blue. At 8% the face assumes a 
leaden color, but distress is not marked. At 5% 
marked panting, clouded senses, loss of power. 
At i%-2% loss of consciousness in 40 to 50 
seconds. If maintained for some time death 
with convulsions occurs when the pressure is dim- 
inished to 6%. 

Effect of an Increased Amount of Carbon Dioxide — 

Death takes place with symptoms differing from lack 
of oxygen. 

Hyperpnea occurs at concentration of 3%. 

Distinct dyspnoea at concentration of 8%, 10%, 15%. 

Chloroform Inhalation — 

Death may occur early or after long, deep anaes- 
thesia. 

The first effect, if much chloroform, is struggling and 
arrested respiration. 

Causes — Distension and dilatation of right ventricle. 
The demand for air causes deep inspiration. 
Blood having much chloroform reaches the myo- 
cardium. In prolonged anaesthesia the effect is 
the same except that respiration leaves first. 

Artificial respiration is of no value in early asphyxia, 
but may be of value in the later stages of an- 
aesthesia. 



76 APPLIED PHYSIOLOGY 

Ether Inhalation — 

Usually produces death by asphyxia, due to depres- 
sion of the respiratory centers. Primary arrest 
in first stages, most likely due to a local irrita- 
tion of the mucous membranes of the air pas- 
sages. 

Caisson Disease — 

Condition produced by the body being subjected to 
very excessive atmospheric pressure. 

The symptoms, pains in the muscles and joints, 
paralysis, dyspnoea and congestion, are most 
likely due to the too rapid decomposition of 
gases in the blood, especially the nitrogen, which 
being liberated suddenly as bubbles, blocks the 
capillaries and produces anemia in the organs. 

Mountain Sickness — 

Produced when the body is in the low atmospheric 
pressure, in mountain climbing, ballooning, etc. 

The symptoms, headache, nausea, weakness and 
vertigo, are due to lack of oxygen, i. e., the 
proper amount of the partial pressure. Other 
unknown factors may exert an influence. 

Cheyne- Stokes Respiration — 

Seen in arteriosclerosis, uremic states, fatty degen- 
eration of the heart, kidney diseases, etc. 

It is always a grave sign in the adult. 

The curve of respiratory movements is: Gradual in- 
crease, climax and a gradual fall, followed by a 



RESPIRATION 77 

pause. The ascending and descending phases 
are about the same in length of time. Average 
is three cycles per minute. 
The real cause is not known, although it is seen to 
occur generally when the nerve centers of res- 
piration are fatigued, or the vitality is lowered. 
The action tends to be periodic. 

Biot's Respiration — 

Sometimes called meningeal respiration. This is a very 
decided pause from several seconds to half a min- 
ute; more or less periodic; is a grave prognostic 
sign. 

Dyspnoea — 

An altered form of breathing, produced by various 
conditions which serve to promote the object of 
breathing. It is generally more rapid and deeper 
than normal breathing. It is increased for the de- 
mands made upon the oxidation processes, and 
when the respiratory processes are obstructed. 

Deficiency of oxygen and excess or carbon dioxide are 
both of importance in the cause of dyspnoea. 

In cyanosis, the difference in color between the arterial 
and venous blood are due to a changed percentage 
of oxygen, and the blue color of the peripheral 
veins is attributable to interference with light rays 
in the skin. The primary cause of cyanosis, seen 
in divers returning to the surface, is the consump- 
tion of the circulating oxygen. 

Condition of collapse in peritonitis, and partly so in 



78 APPIvIED PHYSIOLOGY 

cholera, is due to the reduction of pressure in the 
aortic system, whereby the organs do not receive 
a sufficient supply of blood and become impover- 
ished in oxygen. 

In disturbances of the respiratory apparatus with 
dyspnoea, pronounced cyanosis, occurs only when 
the respiration is not strong enough to arterialize 
the blood through increased pulmonary action. 

Cases of prolonged dyspnoea without cyanosis is seen 
in those affections in which the disturbance of 
respiration is due to direct or reflex excitation of 
the central nervous organs of the respiratory sys- 
tem. It is frequently observed in dyspnoea with 
high temperature, in the heavy breathing which 
precedes coma diabeticum, and in bronchial asthma, 
(von Neusser). 

Forms of dyspnoea : 
That due to pain. 
To diminished breathing surface. 
General circulatory disturbances. 
Disturbances of upper air passages. 
Bronchitis. 
Bronchial asthma. 
Emphysema. 
Uremia of nephritis. 
Febrile. 
Anaemia, 

Orthopnoea — 

Refers to breathing made easier by upright position.. 



RESPIRATION 79 

The appearance of this condition is generally sudden. 
It is most complete from the first. 
After it once appears it generally remains. 
Complete form rarely ever becomes partial. 
When it is partial there is no distress at the angle as- 
sumed. 
Cardiac dilatation is present in most cases. 

Diseases of Respiratory Organs, or Diseased Conditions 
in Which Respiration Is Particularly Interfered With: 

The rate, rhythm and character of respiratory 
movements depend very largely upon the extent to 
which the blood has been oxygenated as it passes 
through the lungs. 

In order to understand the respiratory modifications 
and allied symptoms in diseases of the lungs it is neces- 
sary to explain how temperature, tox aemia and bac- 
teremia influence the medullary center. 

The effect of temperature upon the respiratory 
centers can be seen and explained possibly better than 
the other two conditions; in this particular we have 
the direct experimental evidence of the effect of heat 
on respiration. If it is excessive or prolonged, a marked 
dyspnoea is seen to occur. The explanation being that 
the altered breathing is due to the effect of the heated 
blood on the respiratory center. 

As to the effect produced by bacteria, their toxins, 
and other poisons, we are at a loss to account for much 
of the primary disturbance. Many of these agents act 
locally, some constitutionally, while others act in both 



80 APPLIED PHYSIOLOGY 

ways. Most of the acute infectious diseases, as well as 
the specific toxins, act by affecting one structure more 
than another, and at the same time causing a general 
constitutional disturbance. 

Respiration is both assimilatory and excretory. 
Through the circulation it plays an important part in 
the regulation of temperature., Consequently we note 
that, when we exercise freely and when the body is at 
a higher than normal temperature, the respiratory move- 
ments are accelerated; and attempt is being made by 
nature to compensate for the changes produced. If the 
normal equilibrium is maintained, the actions are en- 
tirely physiological; if they fail, gain and loss of tem- 
perature is not made equal and we have a pathological 
condition. 

There is a marked decrease in the rate of diffusion 
of gases through the healthy and inflamed air cells) 
especially if much exudate is present. 

Normal Respiration Depends Upon — 

Condition of lungs and upper air passages. 

The respiratory movements. 

The action of the heart. 

Condition of blood and blood vessels. 

Character of air breathed. 

Under respiratory movements will be included the 
changes in the chest wall, muscles of respiration, respir- 
atory centers and nerves, and those conditions which 
may mechanically interfere with respiratory movements, 



RESPIRATION 81 

as ascites, together with the most important reflex condi- 
tions modifying respiration. 

Condition of Lungs and Upper Air Passages — 

The functions of the upper air passages are : 

(a) To transmit air to and from the lungs. 

(b) To warm the air. 

(c) To filter the inspired air. 

(d) To furnish a place for the peripheral endings 
of the nerves of smell. 

(e) To protect the lungs from foreign particles by 
reflex action on account of stimulation or af- 
ferent endings in the mucous membrane. 

Obstruction in air passages are due to: 
Occlusion, plugging within. 
Stenosis, changes in walls. 
Compression, pressure from without. 

Changes in nose are chiefly : 
Growths.. 

Hypertrophy of bones. 
Deflection of septum. 
Inflammations. 

Changes in pharynx : 
Foreign bodies. 
Tonsillitis. 

Post pharyngeal abscess. 
Aneurysms of the carotid. 



82 APPLIED PHYSIOLOGY 

Foreign bodies produce dyspnoea by : 

Mechanical obstruction. 
Laryngo-spasm due to irritation. 

Symptoms of respiratory obstruction : 
Dyspnoea — Already explained. 

Stridor — Narrowing of glottis. 

Cough — Irritation of mucous membrane. 
Cyanosis — Nonaeration ; slowing of blood streams. 
Pulse — Effect on the heart and of nonaeration. 

Coryza — 

Headache, chills, malaise, general pains — Due to sys- 
temic effects. Stuffy feeling in head, mouth breath- 
ing, nasal tones, loss of smell, etc., due to swollen 
condition of the mucous membrane and engorge- 
ment of the submucous tissue. 

Sneezing — Irritation of nasal mucous membrane ; direct 
action of the infectious organisms or effect of be- 
ginning inflammation on nerve endings. 

Discharge — Inflammatory exudate. 

Ear, forehead, etc., symptoms due to extension of the 
inflammation. 

Pharyngitis and Tonsillitis — 

Chill, fever and headache due to infection. 

Soreness, etc., due to irritation of pharyngeal and ton- 
sillar nerve endings. 

Stiff neck and painful cervical glands give evidence of 
activity of lymphatic glands in effort to destroy the 
infection. 



RESPIRATION 83 



Loss of hearing due to extension of the inflammation. 

Laryngitis — 

Tickling, soreness, cough, due to irritation of laryngeal 
nerve endings. 

Dyspnoea may be absent or important ; due to narrow- 
ing of laryngeal passage by oedema or spasm. 

Changes in voice due to thickening of mucosa covering 
vocal cords, etc. 

Dysphagia ; due to deep ulceration in the lower pharynx 
and in the epiglottis ; muscular action becomes very 
painful. 

Pseudo-Croup — 

The glottis, which is narrow in children, shows a slight 
swelling of the mucous membrane. Secretions are 
deposited upon the glottis, or if the swelling affects 
the submucosa a transitory occlusion of the glottis 
occurs. 

At times the exact conditions present are not known. 
Laryngismus Stridulus — 

Children; suddenly struggling for breath. 

Give characteristic crowing sound with inspiration. 

Apparently normal after attack. 

May have one or more attacks. 

Cause not known. 

Is a nervous affection. 
Oedema of Larynx (Hydrops Laryngis) — 

Non-inflammatory — part of general dropsy. 



84 APPLIED PHYSIOLOGY 

Local oedema from obstruction. 
Angio-neurotic-oedema. 

O edematous Laryngitis — 

Primary septic infection. 
Secondary to adjoining inflammations. 
Following violent mechanical irritation by steam or hot 
air. 

Foreign bodies. 

Dangerous on account of the inflammation involving the 
loose tissues. 

Laryngeal Stenosis — 

Chiefly due to: 

Diphtheria, paralysis of laryngeal muscles, laryn- 
geal strictures, cicatrices, growths, aneurysms. 

The larynx may permit foreign bodies to enter lungs by : 
Loss of cough reflex. 
Bulbat, etc., paralysis. 
Destruction of epiglottis. 
Swallowing during inspiration. 

The dyspnoea of laryngeal stenosis varies accord- 
ing to the obstruction to inspiration or to expiration, or 
to both simultaneously. If a polypus, croupous mem- 
brane, etc., is located below the glottis, so that a valve is 
formed which leans towards the glottis upon expiration, 
the expiratory dyspnoea presents itself, i. e., a long 
drawn, noisy, difficult expiration following easy, quick 
inspiration. On the other hand, in oedema of the 
glottis, croup, etc., the condition is one of inspiratory 



RESPIRATION 85 

dyspnoea ; in these cases the expiration takes place 
without difficulty, and is rapid and noiseless, but the 
inspiration requires great exertion and is prolonged. 

Neuroses of the Larynx — 

Feeling of titillation, as foreign body sticking fast in 
the larynx, due to hyperaesthesia of hysteria and 
neuresthenia., 

Laryngeal crises of tabes — Due to hyper-irritability of 
branches of the superior laryngeal nerves, produc- 
ing attacks of cough and suffocation. Suffocation 
being due to laryngo-spasm, caused by irritation of 
the motor branch, recurrent laryngeal. 

Deglutition through larynx is due to abolition of cough 
reflex in anaesthesia of mucous membrane of 
larynx. 

Paralysis of Laryngeal Nerves and Muscles — 

Hoarseness and lowering of pitch of voice is due to 
motor paralysis ; a unilateral paralysis of the crico- 
thyroid muscle ; affected cord being low and shorter. 

Immotility of epiglottis — Due to paralysis of superior 
laryngeal. 

Paralysis both recurrent nerves shows : 
Complete aphonia. 
Less ability to cough. 
Glottis and cords immovable.. 

Paralysis of one cord more than other, or incomplete 
bilateral paralysis of the recurrents shows : 
Incomplete aphonia. 



86 APPLIED PHYSIOLOGY 

Deep, hoarse phonation. 
Cough difficult. 

Unilateral paralysis, recurrent laryngeal shows : 
One cord and one side of glottis immovable. 
Fairly good phonation. 
Voice weaker and slightly higher. 

Affections of individual muscles of larynx may give 
variations in the voice and modify breathing. 

In affections of laryngeal nerves it should be re- 
membered that the lesion may be central in the medulla, 
local in the larynx, and outside of larynx, affecting 
branches of the vagus, as aneurysms in upper part of 
thorax, or the affection may be hysterical.. 

Tracheal Stenosis — 

Caused by : 
Ulceration. 

Abnormal openings, accidental or suicidal. 
Extension of diphtheria. 
Pressure from tumors, etc. 
Foreign bodies. 

Rales- 
Crepitations may be either dry or moist. 
Crepitant rale — A crackling sound. Due to: 

Separation of surfaces of collapsed air-sacs, as seen 

in early stages of lobar pneumonia. 
Crepitation of emphysematous lungs. 
Bursting of minute air bubbles. 
Pleuritic friction. 



RESPIRATION 87 

Dry, cracking rale — 

Like the crackling of a dry bladder. 
That form seen in emphysema. 

Subcrepitant rale — 

A form between the two above; this term should 
be discarded. Refers to the crepitant rales 
seen in pulmonary tuberculosis and broncho- 
pneumonia. 

Mucous rales — 

Crepitant, crackling sounds. 

Due to bursting of air bubbles in fluid. 

Bubbling — Large mucous rales. 

Coarse bubbling — The well-known death rattle. 

Sonorous-sibilant rales — ■ 

Rhonchus, or snoring, sonorous. 
Sibilus, hissing or whistling. 

Dry sounds due to the secretion lining and narrow- 
ing the lumen of the tube. If secretion gets 
into cavity of tube bubbles may be produced 
and crepitations arise. 

With exception of mucous rales, all above are gen- 
erally classed as dry rales. 

Bronchitis — 

Constitutional disturbances — Due to general infection. 
Cough — Irritation of vagi endings in the mucosa. 
Substernal soreness — Due to dryness and congestion of 

mucous membrane as well as hypersensitiveness of 

nerve endings. 



88 APPLIED PHYSIOLOGY 

Dyspnoea — Not marked. If present, due to disease ex- 
tending and becoming a broncho-pneumonia. In- 
flammation, narrowing lumen. 

Progressive infection — Due to fact that the epithelium 
with the cilia are destroyed and permit the entrance 
of bacteria.. 

Rales — Due to narrowing of lumen, and to secretions; 
these cause adventitious sounds when air passes in 
and out of bronchi. 

Rhonchus and sibilus — Due to air passing over surface 
of swollen mucous membrane, roughened by secre- 
tions. 

Haemoptysis — Occasional blood is due to rupture of 
small vessels. 

Effect upon heart — Generally the heart is slowed from 
obstruction to entrance of air and to non-aeration. 

In chronic bronchitis added impediment is caused by 
morbid changes in the lungs. 

The obstruction produces : 

Increased tension in pulmonary artery. 

Accentuation of second sound. 

Frequent reduplication of second sound at base. 

To compensate for obstruction : 

Right ventricle beats more forcibly.. 

First sound prolonged over right ventricle, and oc- 
casional reduplication. 

Further effects depend upon the amount and progress 
of the obstruction. 



RESPIRATION 89 

Chronic Bronchitis — 

When compensation fails, referred to above, dilatation 
occurs; the right ventricle first, then right auricle, 
and later the large veins near the heart. 
The congestion spreads backward : 
i — Along the portal system, producing — 

(a) Enlarged liver and ascites. 

(b) Gastro-intestinal disturbances. 

(c) Piles. 

2 — Through systemic veins, producing oedema of feet 
and legs ; albuminuria.. 

Fibrinous Bronchitis — 

Casts — Fleshy pellets or masses. 

Stems and branches of pellets, or casts, correspond to 

the divisions of the bronchial tubes, from which 

they come. 

Structure — Composed of a structureless substance, 
with numerous white cells and few ciliated epi- 
thelia. Streaks of blood, common on the surface, 
probably produced by exudation from blood. 

Broncho-Pneumonia — 

Cough due to irritation of nerve endings by inflamma- 
tion and presence of secretions. 

Fever and rapid pulse due to toxaemia. 

Polypnoea — Partly due to toxaemia, also to lessened 
amount of air cells capable of working properly, 
hence less aeration. 

Pain in side — Involvment of pleurae.. 



90 APPLIED PHYSIOLOGY 

Sore chest walls — Generally due to violent paroxysmal 
cough, which produces a strain and spasmodic ac- 
tion of the expiratory muscles. 

Lobar Pneumonia — 

Chill — Result of toxaemia stimulating centers governing 
the vaso-constrictors of the skin, and this stimula- 
tion, if long continued, would bring about a paraly- 
sis of these centers, causing a flushing of the face, 
which is quite common. 

Fever — Due to toxaemia. 

Headache, general pains, delirium, rapid pulse, and in 
part the respiration, are due to action of toxins on 
various centers. 

Headache, general pains and delirium being probable, 
results of congestion brought about by vasomotor 
paralysis. 

Pain in the side — Due to pleurisy. 

Cough — Irritation by exudate in the air cells. 

Increased respiration — Due to toxaemia; limited air 

space, causing improper aeration, as well as to the 

pleurisy frequently present. 

Sputum (serum, blood cells, and fibrin) — Due to in- 
flammatory exudate. 

Influenza — 

This is a general infection ; frequently the symptoms ap- 
pear to be entirely pulmonary. There is nothing 
peculiar about the attack of influenza except that 
the constitutional symptoms are very severe in com- 



RESPIRATION 91 

parison to the pathological signs, probably due to 
the intensity of the infection. 

Pleurisy — 

Modified respirations depend upon the pain. 

Respiration in pleurisy with effusion is proportionate to 
the rate of increased fluid. May increase slowly 
and show little alteration of breathing, until quite 
an amount is present. This is often seen in the 
pleurisy of tuberculosis. 

Emphysema — 

Dyspnoea due to: 

i — Diminished expiratory power.. 

2 — Decreased aerating surface, consequent to vesic- 
ular atrophy and loss of capillaries in the walls. 
Cyanosis — Due to condition of heart and lungs. 

Hemorrhages in skin, or from nose and mouth — Due to 
venous obstruction. 

Circulatory disturbances — The right heart becomes 
taxed on account of compression of pulmon- 
ary capillaries, etc. 

Heart action affected by coughing attacks, and by 

defective movements of the thorax. 
Right heart hypertrophies. 
Right heart dilates first ; later the left. 

Consequent symptoms may be very marked, both 
systemic and pulmonary. 

Prolonged expiration — Due to diminished elasticity of 
lung tissue. 



92 APPLIED PHYSIOLOGY 

Litten's Sign — 

This is a sign which is seen in various affections of the 
chest, in which the normal excursion of the di- 
aphragm is limited. With the patient reclining on 
a bed in a room with one window, toward which 
the foot of the bed is directed, observation is made. 
A shadow is seen along the sides of the chest, 
which corresponds to the excursion of the diaph- 
ragm, as it moves away from the wall in its de- 
scent. Any condition which will limit the down- 
ward movement will be apparent by shadow. 

Asthma — 

Asthma is an expiratory dyspnoea. 

Probable that the dyspnoea is due to spasmodic con- 
traction of the unstriped muscular fibers in the 
bronchioles. This contraction is most likely due to 
a stimulation of the efferent fibers of the vagus to 
the bronchioles, their stimulation being reflex, 
through irritations of various parts of upper air 
passages.. 

Possible that at times there may be a true inflammation 
of the mucous membrane of much of respiratory 
passage. 

The hindrance to the entrance and exit of air is due to: 

(a) Swelling of the mucus membrane. 

(b) Abnormal secretion of mucus. 

(c) Spasm of the diaphragm induced by stimula- 
tion of the vagus. 



RESPIRATION 93 

(d) Spasm of the muscles of the small bronchi. 
(Krehl). 
The attacks may be produced reflexly ; stimulation most 
frequently being made upon the sensitive parts of 
the respiratory tract, as the turbinates of the nose 
and the surfaces of the finer bronchi. 

Acute inflation of the lung, producing emphysema, is 
due to the deficient passage of air on expiration. 

Pulse small and tense in accordance with the dyspnoeic 
condition of the blood. 

Charcot's crystals and Curschman's spirals are very 
rarely found in the sputum of patients who do 
not suffer from asthma, and they are never absent 
from the sputum which is discharged in asthmatic 
attacks. 

These accumulations of viscid masses of mucus and 
crystals should be regarded as the products of the 
asthmatic catarrh rather than the cause of the 
attacks. (Leube). 

The hypertrophy of the heart and other circulatory 
symptoms depends upon the amount of pulmonary 
disturbances, i. e., the amount of emphysema, al- 
terations of the pulmonary capillary supply, etc., 
which are due to the violent expirations. 

Pulmonary Tuberculosis — 

Rales — Previously explained. 

Dullness on percussion — Due to consolidated areas; oc- 
casionally due to pleuritic effusion. In each case 
absence of air in cells beneath. 



94 APPLIED PHYSIOLOGY 

Tympanitic percussion note — Due to a cavity of some 
size. In percussion over cavity, a cracked-pot 
sound may be heard, due to sudden expulsion of air 
from the cavity through small opening by force of 
the percussion stroke. 

Wintrich's sign — A high note obtained in percussing 
over cavity upon opening the mouth, lower note 
upon closing. 

Gerhard's sign — A high note when sitting; low note 
when recumbent. Occasionally they may be vice 
versa. 

Friedrich's sign — Slight change in pitch, due to respira- 
tion. 

Increased vocal fremitus and increased vocal resonance : 

These are due to the fact that consolidated lung tis- 
sues convey sound better than the normal tissue. 

Cavernous breathing — Transmission of bronchial sound 
into its open spaces, and by passage of air into it. 

Amphoric breathing — Same as above, when the cavity is 
small or when it is so situated that air strikes the 
cavity like blowing over mouth of an empty bottle. 

Cog wheel breathing — Broken, jerky respiration.. Gen- 
erally inspiratory. Due to: 

Irregular muscular action. 

Interference with the passage of air through bron- 
chi, in early tuberculosis. 

Infiltration of apices, when air enters different lo- 
bules at different times. 

Metallic tinkle — Single sound, high pitched, with a 



RESPIRATION 95 

marked echo, produced in large cavities with thin, 

tense, walls. 
Echo due to reverberation in cavity. 
Tinkle due to bursting of bubbles of air through fluid 

in cavity. 
Fever — Due to cocci infection. 

Sputum — Varies in amount and nature. The blood 
present is generally due to the erosion of small 
blood vessels. Round, nummular masses in sputum 
are due to the fact that the sputum is retained in 
cavities for some time, the more liquid part being 
expelled or absorbed, and to the great cohesion of 
its parts. It is airless on account of its retention in 
cavities and to its consistency resisting admission 
of air in the rapid expectoration. 

Prolonged expiratory sound — 

Due to narrowing of tube by secretion or spasm of 
muscular tissue. 

Changes in lung, increasing the conducting power. 

Pectoriloquy — Transmission of voice through cavity and 
to chest walls with unusual clearness. Most 
marked over cavity connected with bronchial tube. 

Hippocratic succussion — Sound produced by movement 
of liquid in large cavity. 

Vomiting — Due to : 
Dyspepsia. 

Result of coughing, probably reflex by irritation of 
pharynx. 

Toxaemia. 



96 APPLIED PHYSIOLOGY 

Diarrhoea — Due to: 

Irritation of intestine by undigested food. 
Catarrhal condition of intestines. 
Ulceration, generally tubercular. 

Sweating — Depends upon the general condition of the 
patient. 

Generally follows a fall of temperature (hectic 
fever), in which it is due to dilatation of ar- 
terioles. 
Hoarseness — Generally due to tubercular laryngitis. 
Pain — Due to: 

Concurrent pleurisy or neuralgia. 
Result of coughing. 

Albuminuria — 

Febrile albuminuria. 

Chronic parenchymatous nephritis. 

Amyloid degeneration of kidney. 

Haemoptysis — Due to: 

i — Tubercular granulations in walls lessen the re- 
sistance and small vessels may rupture. 

2 — Rupture of vessel in wall of cavity. 

3 — Erosion or rupture of an aneurysm, generally 
in wall of cavity.. 

Change in Respiratory Movements — 

Altered respiratory center. Due to brain trouble, 
uraemia, poisons, Biot's and Cheyne-Stokes repira- 
tions, etc. 

Lesions of centers in cord, etc. 



RESPIRATION 97 

These lesions in cord or in course of nerves will affect 
the part supplied; the symptoms appearing being 
due to paralysis of diaphragm, intercostal muscles, 
etc. May have paralysis of respiratory muscles in 
apoplexy. The slow and deep respiration in apo- 
plexy depends upon changes in respiratory center. 

Abdominal conditions — 
Ascites. 

Enlarged liver. 
Painful areas, as perineal abscess. 

The cause of modified breathing in all these cases is 
quite apparent, being due to mechanical interfer- 
ence during inspiration. 

Alterations in chest wall — When size and shape of 
chest wall is altered,,, or a rib is fractured, etc., 
breathing is changed in proportion to limitation of 
chest expansion, and to occurrence of pain. 

Reflex action — Respiratory changes may be brought 
about reflexly by stimulation of nerves of sight, 
hearing, etc., psychic conditions, irritation of vari- 
ous peripheral sensory nerves, etc. 

Haemoptysis — 

Blood-stained sputum may appear as : 

i — Watery fluid, stained with blood; pink or bright 
red, coming from gums or mouth. 

2 — Streaks of bright blood, upon outside of pellets 
or strings of mucous — from large air tubes or 
pharynx. 



98 APPLIED PHYSIOLOGY 

3 — Viscid pellets, containing minute air bubbles ; 
pink, red or rusty, sometimes prune juice hue. 
Lobar pneumonia. 

4 — Small solid lumps, purple or black, no air 
bubbles; sink in water — due to rupture of dis- 
tended capillaries in the wall of air cells. The 
dark color signifying time in lung before ex- 
pulsion. 

5 — Pure blood, generally bright red — 

(a) Brought up at short intervals in small quan- 
tities. 

(b) Gushes of blood, with little or no air. 

If bright red, respiratory organs or stomach. 

6 — Blood clots, bulky, gelatinous. From stomach 
or lungs. If from lungs they are moulded to 
shape of bronchial tubes. 

Respiratory Modifications Due to Circulatory Disturb- 
ances — 

Cardiac dyspnoea — Tachypnoea at first due to exertion. 
Probably due to vagus supplying heart and lungs. 
In late cardiac disease, definite dyspnoea is present. 
Condition due to deficient aeration of the blood is 
compensatory, not associated. 

Renal dyspnoea — May be dyspnoea of late cardiac dis- 
ease, but in uremia it resembles spasmodic asthma. 

Altered condition of blood — Increased respiration is due 
to the deficient amount of oxygen in the blood. 
Also due to effect of blood upon respiratory center. 



DIGESTION 99 

CHAPTER IV. 

DIGESTION. 

Digestion has been named by common consent as the 
first sub-division of the arbitrary term, nutrition. Nutrition 
is said to include all those changes which take place in the 
food and its products, from the time it is taken into the 
mouth until it has undergone all necessary changes for its 
incorporation into the various tissues; further it includes 
those metabolic changes which take into account the pro- 
cesses of building anew the various cells, as well as that of 
their destruction. 

Nutrition cannot in the strict sense be considered to 
deal alone with the food and its changes. The circulation 
of the blood ; the respiratory processes in the blood tissues ; 
the innervation of the structures, all are important functions 
continually acting with and upon the food products and af- 
fecting the glands which pour out the various digestive 
juices as well as the structures which carry these substances 
from one part to another. 

When we state the processes of nutrition are not normal 
we do not mean to convey the idea at all times that the stom- 
ach or liver is not performing its function. Probably it may 
be due to the diet ; again some internal secretion may be at 
fault; a concealed tumor may by interference with the cir- 
culation cause a passive congestion altering gladular ac- 
tivity. A true anemia may exist and the evidence foir a 
time only be seen in the malnutrition of the body. In other 

1.0FC 



100 APPLIED PHYSIOLOGY 

words a proper nutrition means that the various structures 
of the entire organism are working normally and in har- 
mony. A good external appearance is by no means a cri- 
terion of good nutrition.. 

The secretion of ferments is not dependent upon the 
nervous system as are the digestive juices. 

An immediate and proportionate reduction of ferments 
is not usually an accompanied condition of altered secretion 
of digestive juices of neurotic origin or transient as in fevers. 
In all atrophic and destructive lesions of the gastric mucosa 
a reduction of the enzymes runs parallel with the extent of 
the process. 

Digestive ferments are to date: Ptyalin, maltase, pep- 
sin, chymosin, a gastric lipase, trypsin, steapsin, amylopsin, 
invertin, erepsin, enterokinase and secretin. 

Digestion includes those changes which occur in the 
food from the time that the food is thought of until it is 
prepared for absorption. For these processes we have the 
various parts of the alimentary canal, including the diges- 
tive glands and the nerves supplying all these. 

In order that digestion may be perfect it is essential 
that the food be such that it will not require too much time 
and work in its preparation; that the products be removed 
at the required time and that no organ must suffer from 
the work being accomplished, either an organ of digestion 
or an extraneous one, as the heart. 

The Mouth — We here find the structures, teeth, 
cheeks, tongue, etc., which take the food and by proper 
movements allow the respective salivary juices to act upon it. 



DIGESTION 101 



Anything which will interfere with the movements of the 
jaws, cheeks or tongue, any alteration in the quantity or 
quality of salivary secretions, or bad teeth, becomes a patho- 
logic condition which may cause altered salivary digestion 
and still be more liable to disturb the gastric digestion. 

The normal movements of the jaws, tongue and cheeks 
are interfered with mostly by paralysis of the cranial nerves, 
tumors, tetanus, injuries, etc. The cause of altered condi- 
tions is in most cases quite apparent ; those caused by changes 
in the nerves may at times be a little difficult to explain, as 
nearlv all the changes due to the nerve disturbances either 
central or peripheral or central, are those affecting the 
cranial nerves and will be considered in detail under that 
subject. 

Improper preparation of the food in the mouth, and the 
presence of many micro-organisms, favored by retained food 
in and about the teeth, is followed by putrefactive and fer- 
mentative changes which eventually greatly alter proper 
digestion in the entire alimentary canal. 

Coated Tongue — Found in many healthy persons. If 
normal shedding of epithelia is suspended in affections which 
interfere with ingestion of food, or if the tongue is placed 
in a condition of rest by painful affections of the mouth, 
etc., a coating is formed by the growing fascicular processes 
or more marked proliferation of the horny layer with bac- 
teria. 

The saliva is normally slightly alkaline. When the 
food is passed into the stomach the conditions there favor 
a continuance of salivary digestion in that place for prob- 
ably one-half to two hours. Should the reaction of the 



102 APPLIED PHYSIOLOGY 

saliva be markedly acid, salivary digestion is consequently 
hindered. 

Saliva may be acid in certain diseases, as rheuma- 
tism, gout and diabetes, where abnormal acids are found in 
the blood. 

The amount of saliva discharged from the various 
glands depends largely upon the blood pressure, other fac- 
tors remaining normal. It is said that in many cases an 
excessive flow of saliva has been noticed to lessen the amount 
of ascites in general dropsy. 

Potassium sulphocyanide in the saliva may be in- 
creased or diminished in quantity. It is thought that the 
amount of this substance present is indicative of the func- 
tional activity of nutrition. When the power of nutrition is 
lessened there seems to be often a diminution of potassium 
sulphocyanide. 

Stomatitis is due to irritants affecting the mucous 
membrane or to infection. Frequently a simple mechanical 
or chemical irritation may so weaken the resistance of the 
mucous membrane that infection is allowed to occur. 

SALIVATION. 

Nervous Mechanism of Salivation — 

The cranial nerves supply the glands with vaso-dilator 
fibers and with secretory fibers. 

The sympathetic nerves supply the glands with vaso- 
constrictor fibers and with secretory (trophic) 
fibers. 



DIGESTION 103 

The secretory fibers are those controlling: 

(a) The secretion of water and salts. 

(b) Those controlling metabolism of the cells. 

Disturbances of Salivation through the nervous mechan- 
ism — 

Due to irritation of the sensory nerves, as is the chief 
cause in stomatitis. In which case the irritation 
acts similarly to that of a foreign body, where 
nature increases the flow to remove the foreign 
substance. Again it may be due to reflex stimula- 
tion of the center in the medulla, causing increased 
flow of saliva. 

In bulbar paralysis salivation occurs through effect on 
the center. 

In Graves' disease it is due to irritation of the sym- 
pathetic. 

In trifacial neuralgia the secretory fibers are affected 
both directly and reflexly. 

In facial spasm salivation may be seen when irritation 
of the fibers passing to the parotid gland occurs. 

In mercurial poisoning the cause is due to irritation of 
the secretory fibers by mercury in the blood. A 
secondary effect is seen in the action of the mer- 
cury upon the glandular cells themselves 

Disturbances of salivation also occur in paralytic effect 
of atropine on the chorda tympani, through the 
secretory fibers. 

Lesions of the chorda tympani : Stimulation causes 
vaso-dilation and disturbs the secretory fibers. 



104 APPLIED PHYSIOLOGY 

The sympathetic supply is subjected to the same vaso- 
motor impulses as are seen in the fall of blood 
pressure due to shock, etc. 

Foetid Breath— 

This condition is almost always indicative of disturb- 
ances in the alimentary canal. While affections of 
the mouth and stomach are more liable to produce 
the condition, yet pathalogic processes of the in- 
testines may be evidenced by the discharge of foul 
gases in the breath. At times the. cause may be 
respiratory trouble, especially when any purulent 
processes are present, seen in the nares, bronchi, 
etc. The seat of the cause may be in the adjacent 
structures as in the eustachian tube. 

In the alimentary canal the foul breath is due to any 
change which will allow the food to remain in one 
location for some time, and become acted upon by 
various micro-organisms ; this is seen in retained 
food in the mouth, diverticula of the oesophagus, 
and atony of the stomach and intestines. Again it 
may be caused by an alteration of the normal diges- 
tive juices which have as one function the destruc- 
tion of bacteria ; seen in hyperchlorhydria. Foetid 
breath is a very common symptom of that complex 
"dyspepsia" generally regardless of the cause or 
location. 

Deglutition — 

The act of swallowing is divided into two parts ; that for 
the passage through the pharynx and that for the 



DIGESTION 105 

passage through the oesophagus. When the food 
reaches the posterior part of the tongue it becomes 
an entirely involuntary act. 

The afferent impulses are normally started by contact 
of food or saliva with the mucous membrane of 
the various parts of the structures concerned in the 
first part of the involuntary act. These impulses 
are carried to the center for deglutition which lies 
in the medulla. Afferent impulses are carried 
through the pharyngeal and superior laryngeal 
branches of the vagus and palatal branches of the 
fifth nerves. 

Efferent impulses are carried through the twelfth, ninth, 
tenth, seventh and fifth cranial nerves. 

Dysphagia — 

The guarding of the posterior nares is interfered with 
in affections of the soft palate; food being regur- 
gitated through the nose. Guarding the laryngeal 
opening is a very important phase in deglutition., 

Dysphagia may occur in diseases of the mouth, fauces, 
pharynx, larynx or oesophagus. 

The chief cause of the difficulty in recognizing pharyn- 
geal trouble is rheumatism. 

Laryngeal dysphagia is recognized by pain and the 
falling of food particles into the larynx, exciting 
cough. 

Oesophageal dysphagia may be due to disease in the 
canal, including foreign bodies, or to disease out- 



106 APPLJED PHYSIOLOGY 

side making external pressure, etc. The causes of 

dysphagia may be classified thus : 

i — Inflammatory conditions of the canal, as pharyn- 
gitis, tonsilitis, where the part is irritated by the 
food. 

2 — Narrowing of the passageway by non-inflamma- 
tory growths, etc. 

3 — Hypersensitiveness of the mucous membrane 
causing cough or vomiting. 

Carcinoma of the Oesophagus — 

Dyspnoea, angina pectoris — Due to pressure upon the 
vagus. 

Paralysis of the vocal cords — Due to the same cause. 

Regurgitation of food shows constriction. 

Diagnosis of location of stenosis of the oesophagus : 

Symptoms and signs of extra or intra-oesophageal 
trouble. 

Presence of sugar in retained or regurgitated food, 
due to digestion of starches. 

Foetid odor if a cavity has formed and if food is 
old. 

Absence of pepsin in the food. 
Reaction is neutral generally. 
Sounding when permissible with a stomach tube- 
When solids are swallowed better than liquids in 

stenosis of the oesophagus the trouble is generally a 

spasm, seen in the neurotic. 

When inability to swallow exists without any evi- 



DIGESTION 107 

dence of cause upon examination, it is generally hysteri- 
cal. Most cases are seen in females, but males are 
not excluded. 

THE STOMACH. 

This organ has three chief functions : Digestion of pro- 
teins, reservoir for continuance of salivary digestion and 
destruction of bacteria. 

The position and size may be made out by inflation by 
means of a seidlitz powder or air, and percussion made ex- 
ternally ; or the stomach may be illuminated by a small 
electric light internally. 

The motility of the stomach may be ascertained by ad- 
ministering salol and in about 75 minutes salicylic acid will 
appear in the urine ; tested by chloride of iron, which gives 
a blue color. 

The absorption power of the stomach may be ascer- 
tained by taking a few grains of potassium iodide ina cap- 
sule soluble in the stomach, the time required to appear in 
the saliva being taken as the absorptive power of the stomach 
with slight correction for breaking up of the capsule and 
for the time elapsing from entrance of the drug into the 
blood and making the test. 

Desmoid Reaction — This reaction has as its principle 
the fact that the gastric and pancreatic juices act inde- 
pendently and in a totally different manner. Sahli, after 
some experiments., has decided that methylene blue and 
iodoform are most suitable, as they are excreted by the 
urine and can be easily' recognized therein. To pro- 
tect them from the action of the pancreatic and intes- 



108 APPLIED PHYSIOLOGY 

tinal juices they are made into a small pill, wrapped in 
a small square of rubber tissue, and protected from the 
intestinal digestive ferments by closing the rubber tis- 
sue bag with catgut. As both catgut and rubber tissue 
are impermeable to pancreatic and intestinal juices the 
methylene blue and iodin do not appear in the urine if 
the gastric juice is deficient. In case of normal gastric 
digestion the catgut string is dissolved, allowing the 
square of rubber tissue to be opened and permitting the 
absorption of the methylene blue and iodin. 

In order to estimate the digestive power of the stomach 
it is possible to remove the contents of the organ at dif- 
ferent periods of time after taking a normal meal, or as is 
generally done a test meal of a roll and tea or some such 
diet is given, and after an hour this is removed by the 
stomach pump. While much may be learned by the use of 
such tests, the results are not as good as were anticipated. 
The artificial diet and methods often altering the pro- 
cesses which actually exist ; further, the accessory influences 
are such that the results are by no means constant. 

Normally the stomach contains quite a fixed per cent 
of HCL and pepsin in solution. These furnishing the active 
constituents of the gastric juice. A second ferment is found, 
chymosin, which has power of curdling milk. After a diet 
rich in carbohydrates, lactic acid may be found in the gastric 
juice. The stomach may be divided by the sphincter antri 
pylorici into two important divisions, the part between the 
sphincter and the pylorus called the antrum, and that part 
to the left of the sphincter called the fundus. Digestion 
takes place in the antrum. Movements of the stomach are 



DIGESTION 109 

divided into the movements of the two sections.. When 
food is digested it passes through the pylorus and then more 
passes out into the antrum. The food does not enter the 
stomach, pass to the left into the cardia, along the lower 
portion of the stomach to the pylorus and back again to the 
cardia as was formerly believed. 

Nervous Mechanism of the Stomach — 

Efferent fibers pass through the vagus and sympathetic 

(splanchnic). 
Afferent fibers pass through the vagus from the 

stomach. 

Cranial stimuli, afferent impulses, producing reflex ac- 
tion, reach the center through the nerves of sight, 
taste and smell, etc. 

Movements of stomach may take place regardless of 
nerves to it. The muscles are capable of spon- 
taneous contractions. 

Vomiting — 

Vomiting may be divided into (a) central, e. g., that 
caused by apomorphine, and (b) reflex, which may 
be local as to seat of the irritant, e. g., irritating 
food in the stomach, or it may be distant from the 
stomach as in the passage of renal calculus, or the 
sight of disgusting food. 

Seen in the initial stages of many fevers due to the ac- 
tion of toxins on the center or to impulses from an 
irritable brain. 

Vomiting of septicaemia and uraemia is largely due to 



110 



APPLIED PHYSIOLOGY 



the presence of toxic substances in the blood acting 
upon the center directly. 

That of hysteria may be due to non-control of vomiting 
center by higher centers. The vomiting center is 
closely related to the respiratory center. 

In intestinal trouble the time and amount of vomiting 
depends much upon the location of the disturbance ; 
when it is in the upper part of the small intestine 
it is early and often severe, while in the large in- 
testine it has a slow onset and often none. 

Afferent nerves to the vomiting center: 

Pharyngeal branches of the glosso-pharyngeal. 
Pulmonary branches of the vagus. 
Gastric branches of the vagus. 
Gastric branches of the splanchnic (?) 

Renal, mesenteric, uterine, ovarian and vesicle 
nerves. 

Fibers from organs of special sense; from brain 
substance or membranes or from central 
ganglia excited by emotion or imagination. 

These afferent paths show the possible reflex arcs for 
most cases of reflex vomiting. 

The vomitus consists of acids, foods, micro-organisms, 
blood, pus, bile, animal parasites, etc. 

The cause of the presence of each of the above sub- 
stances is usually quite clear in each instance. 

Anorexia- 
Loss of appetite is referred especially to disturb- 



DIGESTION 111 



ances of the stomach, body tissues and the brain. Ap- 
petite is due to demand from the named structures. The 
chief factor in creating a good appetite is the normal 
condition of the body ; but this may be greatly influenced 
by psychical influences as well as reflex inhibition and 
stimulation of certain afferent nerves, e. g., those of 
smell and sight. So great in this last action that Paw- 
low calls the appetite a juice ; which shows its effect by 
action on the nerves, which causes the secretion of di- 
gestive juices. Probably nowhere in the entire body is 
the observer so likely to err as to the cause of dim- 
inished flow of digestive juices, with the primary loss 
of appetite. 

In seeking for an explanation of the altered diges- 
tive functions, the influence of the mind of the patient 
as well as his environment, must always be borne in 
mind. 

Bad Taste- 
Usually due to an acute catarrh ; may be chronic.. 
Local causes, e. g., diseases of the mouth, bad teeth, etc. 
Medicines. 
Metallic poisons. 
Constitutional disturbances. 

Thirst- 
Due to gastric disorder. 
Excessive secretions. 
Loss of liquid to the body, e. g., diarrhoea, perspiration, 

vomiting and hemorrhage. 
Fever. 



112 APPLIED PHYSIOLOGY 

Diseases, e. g., diabetes. 

Distress, weight, burning, etc., due to flatulence, acidity, 
etc. 

Nausea — 

Akin to vomiting in mechanism and clinical associations. 
Generally associated with salivation. 
Failure to vomit is often due to lack of completeness in 
required muscular efforts. 

Flatulence — 

Gas in the stomach and intestines. 

Fermentation of fatty foods. 

Carbon dioxide generated and retained on account of 
atony. 

Air swallowed. 

Regurgitation of pancreatic juices, causing flatulency, 
due to decomposition of carbohydrates which lib- 
erates the C0 2 . 

Bacterial fermentation. 

Interchange of gases between the blood and contents 

of the stomach. 
Hysteria. 

Pyrosis — 

A burning sensation felt in the epigastrium — heart burn. 

Thin fluid believed to be secreted in the stomach ; 
thought by some to be saliva retained in the lower 
part of the oesophagus. This regurgitation of fluid 
is called water brash. 



DIGESTION 113 



Acid eructations — generally a hyperacidity. 

Gaseous eructations — belching of gas due to indigestion. 
See flatulence. 

Abnormal Constituents of gastric Juice — 

Alcohol. 

Alkalies — Sodium carbonate acts only upon the juice 
already secreted, not as a secretory mechanism. 

Acids — Normally a large amount of HCL is required, 
ioo grams of meat require about 55 c. c. of diluted 
HCL. Good effects from small doses of HCL, at- 
tributed to the action of the more highly acid chyme 
in the duodenum and more thorough disinfection 
of the food. 

Bitter tonics — The object is attained by exciting a sharp 
unpleasant gustatory impression, which by contrast 
awakens pleasant ones. 

Excessive Secretion of Mucus — 
Due to catarrhal affections. 

Alcoholic form, much tenacious mucus, and when 
vomited in the morning called the "vomitus matu- 
timus." 

Effects — Digestive processes are interfered with in a me- 
chanical way. Increased alkalinity in the stomach 
may prolong starch digestion. Nausea is usually 
present ; often vomiting. 

Hyperchlorhydria — ( Hyperacidity) . 

Form and causes : 

1 — Occurring in acid gastritis. Due to irregular 
diet, drinking and smoking. 



114 APPLIED PHYSIOLOGY 

2 — Occurring in stenosis of the stomach. 

3 — That caused by chronic constipation. Seen in 
constipation, particularly when due to spastic 
condition of the colon. 

4 — Occurring in neuesthenia and hysteria. A secre- 
tory neurosis due to disturbances of the nervous 
system. 

5 — Occurring in gastric crises. (Paul Cohnheim.) 
Results of hyperacidity — Inhibition of normal salivary 
digestion in stomach. Proteolysis augmented. 

Motility may be increased later generally motor insuf- 
ficiency due to inflammatory processes in the mu- 
cosa and musculature. 

Vomiting due to irritation. 

The highly acid chyme causes an increased pancreatic 
action. 

Constipation — Probably due to thorough disinfection of 
the food by HCL. 

Hypochlorhydria — (Hypoacidity) . 

Due to — Diseases to the mouth and perversions of the 
appetite. 
Shock — Result of central impulses. 
Drugs as morphine — Inhibit secretory activity. 

Alterations of the glandular structure — As seen in 
gastritis, fever, cancer, etc. 

General atrophy of old age. 

Effects — Salivary digestion in the stomach may be pro- 
longated. 



DIGESTION 115 

Peptic digestion does not occur. 

Motor power reduced. 

Dyspeptic symptoms. 

Reduced stimulation of the duodenal mucous men> 
brane. 

Passage of the pathogenic germs into the intestine. 

Constipation and tympanites. 

Intercurrent diarrhoea due to decomposition prod- 
ucts. 

Hiccough — 

This may be a serious condition. 

Due to sudden contraction of the diaphragm. 

Local causes — Chiefly diseases of abdominal viscera, 
associated with diaphragmatic peritoneum. 

Central causes — Diseases of the brain and constitu- 
tional diseases. 

Reflex causes as in pregnancy. 

Dyspepsia — 

A generic term implying improper digestion pro- 
ducing disturbances referred to alimentary tract. 

Due to excessive mucous and irritation of undigested 
food. 

Thirst due to increased secretions; slight inflamma- 
tory conditions of the mucous membrane. 

Cardialgia — Due to pressure of gases and reflex ac- 
tion. 

Giddiness — Reflex action upon the central nervous 



116 APPLIED PHYSIOLOGY 

system transmitted by irritation of the gastric 

nerves. 

Yawning — Insufficient respiratory changes. 

Coated tongue and herpes labialis. 

Fetid breath — Fermentation and putrefaction. 

Altered stomach contents — Abundant mucus ; de- 
ficient amount of digestive secretions; lessened 
motility. 

Altered pulse rate — Reflex action. 

Palpitation of the heart — Especially due to pressure 
of gases : H and C0 2 from fermentation. 

Vomiting — Cause is generally local. 

In atrophy of the gastric mucous membrane, as 
soon as the motility of the stomach becomes im- 
paired, signs of dyspepsia set in ; also upon cessation 
of secretion of HCL, the acidity of the urine does not 
show the decrease as under normal conditions of 
digestion. When diarrhoea follows it is due to the 
atrophic condition of the intestine. 

Gastric Ulcer — 

Pain — Paroxysmal ; follows ingestion of certain foods 
as hot or cold ; irritation of accumulating acids. 

Usually concentrated in one locality. Intensity 
depends upon the position of the patient, due to the 
tugging of the nerves in the ulcer or direct chemical 
or mechanical irritation of the surface of the ulcer 
by shifting of the stomach contents — generally at the 
pit of the stomach. 



DIGESTION 117 



Hemorrhage — Blood generally bright red; quantity 

varies; intervals may be months apart. 
Tumor — Thickening often not felt. 
Dyspeptic symptoms — Pressure sensations. 

Vomiting generally shows an increase of HCL — Due 
to glandular stimulation, etc. ; increase of HCL 
not a constant symptom. 

The HCL may be the cause rather than the result of 
the ulcers. 

Carcinoma of the Stomach — 

Symptoms of chronic gastric catarrh — Due to the in- 
flammatory processes. 

Tumor. 

Pain — Due to the presence of food and movements 
of the stomach. 

Pain characteristic of cancer in the peculiar involve- 
ment of the nerves. 

Vomiting— Coffee-ground like masses due to the re- 
tained blood, the haemoglobin being changed by 
the gastric juice into haematin. 

Oedema — Due to the anemia which exists and the 
mechanical interference of the venous circula- 
tion. 

Absence of HCL — Due to extension of infiltration 
and glandular atrophy to accompanying catarrh 
and progressive cachexia. It appears that the 
cancer cells have a specific affinity for the stom- 
ach glands. 



118 APPLIED PHYSIOLOGY 

Presence of lactic, butyric, acetic, etc., acids — Due 
to chemical products of disintegration of ingesta 
retained in the stomach beyond normal limits. 

Gastrectasis — 

Dyspeptic symptoms due to mechanical interference 
with the circulation of the stomach ; atony of the 
walls; retained food; true catarrhal condition 
frequently present. 

Habitual vomiting — On account of great atony, food 
may be of great quantity and old. All kinds of 
fungi may be present. 

Gastralgia — 

Violent pains — Spasmodic on account of being neu- 
ralgic. 

Radiating for the same reason. 

Relieved by food — True when pain is due to exces- 
sive acidity. 

Relieved by pressure — When pain is due to accumu- 
lation of gas. 

Neuroses of the Stomach — ■ 

Nervous dyspepsia — Both motor and sensory. 

Due to altered sensibility, contractility, amount and 
quality of secretion. 

Includes those affections of the stomach where dis- 
turbances are restricted to the nervous apparatus 
of the stomach, i. e., no anatomic affections 
are found outside of the nervous system. 



DIGESTION 119 



Altered appetite — Due to mental influences, altered 
secretions and movement of the stomach. 

Nausea — Due to phychic influences chiefly; to a less 
extent to impaired digestion. 

Vomiting due to the same cause. 

Mental depression — Generally a part of hysteria or 
neurasthenia, some etiologic factor as worry, 
shock, etc. 

Epigastric pain due to accumulation of gas; hyper- 
sensitiveness of nerves, etc. 

Headache — Due to mental depression; eyestrain. 

These last are causes rather than result of poor di- 
gestion. 

Motor Insufficiency — 

Due to anemia. 

Excesses as alcohol, tobacco, etc. 

Emotions. Organic nervous diseases. 

Hereditary weak stomach. 

Diseases of gastric musculature. 

Dislocations of the stomach. 

Pyloric stenosis. 

Effects — Stagnation of food. 

Improper retention of food. 

Deficient mixture of food with juices. 

Tendency to displacement. 

Pressure effects upon adjoining viscera. 

Chemical and anatomical variations. 

Sensorv disturbances. 



120 APPLIED PHYSIOLOGY 

INTESTINE. 
Intestinal Movements — 

The normal intestinal movements are of two kinds : 

(a) A gentle swaying pendulum motion ; 

(b) A true peristalsis in segments. 
Peristalsis of the intestine is governed by local reflex 

nevous mechanism (Auerbach's plexus). 

The splanchnic nerves contain fibers for inhibition. 

Auerbach's plexus (from the sympathetic) is situ- 
ated between the muscular coats of the intestine. 
Branches from these form a secondary plexus, 
Meisner's, beneath the mucous coat. 

In order that the movements may be normal it is 
demanded that : 

i — Intestine be normal with perfect nervous me- 
chanism and glandular action. 

2 — Products of digestion do not cause too great 
or too little stimulation of the mucous mem- 
brane. 

3 — There be absence of foreign substances, gall 
stones, toxic substances, etc. 

4 — There be absence of compensatory effort to 
relieve other organs as diarrhoea on account 
of a diseased kidney. 

5 — Central influences do not cause increased per- 
istalsis by removing inhibition, as in the case 
of fear. 

6 — The person have regular habits which will 
produce a normal stimulation. 



DIGESTION 121 



DIARRHOEA. 

This implies an increased intestinal peristalsis ; but 
not all increased peristalsis is diarrhoea. Anything which 
may alter any of the above conditions may modify nor- 
mal peristalsis, which is liable to increase the intestinal 
movements and explain the occurrence of a diarrhoea. 

Nervous Diarrhoea — 

Nervous influences frequently cause a transient alter- 
ation of pancreatic and biliary secretions — hence 
undigested food. 

Emotion and fear cut off the inhibitory impulses. 

Diseases of the brain and cord. 

Reflex irritation., chiefly from some abdominal organ. 

Catarrhal Diarrhoea — 

Cold : causing inflammation of the mucous mem- 
brane. Irritation and much secretion. Irritants, 
as food, stimulate peristalsis by action on the 
mucous membrane locally. 

Irritants, as bacterial products, act in a way similar to 

the last, but more reaching. 
Infections, as in summer diarrhoea in children, etc. 
Ulcers, etc. 

Toxic Diarrhoea- 
Poisons act mostly by great irritation. 

Vicarious Diarrhoea — 

As in B right's disease to remove poisons from the 
body. Irritation of the intestine generally causes 



122 APPLIED PHYSIOLOGY 

diarrhoea, these increase the intestinal peristal- 
sis to remove the offending substance. When 
classed here they do not cause a catarrhal con- 
dition. 

Spurious Diarrhoea — A diarrhoea of constipation. 

Stools- 
Little water: 

(a) Seen in constipation. 

(b) Loss of liquids to the body. 

(c) Diseases as fever, etc. 

Abnormal substances: 
i — Undigested food. 

(a) Fatty stools, suggestive of disease of the pan- 
creas. Also follows ingestion of much fatty 
food. 

(b) — Undigested condition shows lack of diges- 
tive powers, or too rapid peristalsis from some 
cause. 

2 — Mucus — Seen in inflammatory conditions. 

3 — Blood — Generally shows by its appearance the 
source of its origin, as the darker and older, the 
more liable to have come from high up in the 
small intestine or stomach. 

4 — Pus. animal parasites, etc., suggest in themselves 
the source. 

5 — Shreds of mucous membrane show a more severe 
degree of inflammation than simple catarrhal in- 
flammation, associated with mucus. 



DIGESTION 123 



6 — Biliary substances — Most frequently associated 
with rapid peristalsis. 

Color of the stool — In health the stool is colored 
with bile pigments. 

Form of the stool indicates the rate of peristalsis 
with the presence of a stricture. 

Odor — Normally due to indol and skatol. Exces- 
sive odor especially indicative of too great putre- 
factive changes. When not due to diseased con- 
dition of the intestine, generally caused by im- 
perfect digestion and absorption of nitrogenous 
foods. 

Defecation — 

Normal process implies a stimulation of the rec- 
tum or lower bowel, which by reflex action through 
the higher centers cuts off action of the anal 
sphincters and at the same time sends impulses 
(motor) to the intestines. Frequent stools in a per- 
son suffering from any irritating lesion in the rectum 
is easily explained; likewise the value of a glycerine 
suppository. 

Pain on defecation — Due to local causes, as ulcers, 
hemorrhoids, nature of the stool, consistency, 
size and composition. 

CONSTIPATION. 

Due to : Alteration of, or diminution in amount of the 

secretions. 
Diminished sensibility of the nerves. 
Free perspiration. 



124 APPLIED PHYSIOLOGY 

Free diuresis — Seen in diabetes, etc. 

Debility (atony) of the muscles. 

Improper diet. 

Paralysis — Brain and cord lesions. 

Atony as in peritonitis ; paretic state of the bowels 
(ileus paralyticus). 

Pain — Fear leads to constipation as in fistulo, ulcers, 
etc. 

Drugs and habit. 

Symptoms in constipation — Impaired digestion. 

Dark or muddy complexion, due to absorption of 
detrimental substances. 

Fullness after eating, flatulence, etc. 

Impossible to explain why some persons may have 
bowel movement once in from one to three 
weeks and apparently not suffer as much as 
others who may fail to have a daily movement. 

Without doubt the absorptive power of the latter 
class is much greater than in the constipated. 
Yet paradoxical though it may seem to the last 
statement, the amount of solids and liquids taken 
into the bod}' must be more perfectly absorbed 
than in those who suffer from constipation of 
one day. Certainly we do not yet understand 
the immunizing power of the intestines, nor the 
part played in peristalsis by the substances ex- 
creted into the intestines. 

Secondary symptons of constipation — Dilatation of 
the bowel. 

Ulceration. 



DIGESTION 125 

Incontinence of Feces — 

Seen in the insane; delirium; coma; paralysis; injury 
to the bowel. All but the last being due to the 

removal of cerebral inhibitory action. 

Ileus — 

Term signifying intestinal obstruction. 
By some confined to a paralytic obstruction ; by 
other means intussusception. 

Coprastasis — 

Impacted fecal matter. 

Intestinal Obstruction — 

Due to: Mechanical obstruction by foreign bodies, 
tumors, bands, feces, etc. 

Poisons, as lead., causing spasm; relieved by mor- 
phine, which paralyzes the inhibitors in large doses. 

Nervous — As in lesions of brain or cord. 

Reflex from stimulation of the inhibitory nerves as in 
renal colic, etc. 

Vomiting — Generally reflex; at first from the bowel, 
later from peritonitis. May have actual reversed 
peristalsis, hence vomiting. 

Pain, early due to damage to the bowel ; late pain 
due to distention and futile peristalsis; finally 
due to peritonitis. 

Tympanities — Bacterial multiplication, putrefaction 
and fermentation. 

Acute Catarrhal Enteritis — 

Diarrhoea from inflammatory processes. 



126 APPLIED PHYSIOLOGY 

Pain due to the same cause. 

Thirst due to loss of liquid to the body. 

If inflammation is a simple acute condition of the 
jejunum and ileum, without inflammation of the 
large bowel, there is little diarrhoea. The lower 
down in the bowel the inflammation is, the purer 
is the mucus and the more tenesmus. 

Undigested food is due to rapid peristalsis, excessive 
mucus coating the bowel and lessened digestive 
secretions. 

Green stools of children due to large amount of bile. 

Appendicitis — 

Sudden pain — Retained secretions under pressure on 
account of inflammation. 

V omiting — Reflex. 

Constipation — Due to paralysis of the bowel. 
Diarrhoea — Due to inflammatory irritation. 
Fevers, chills and constitutional symptoms due to 
infection. 

Rigidity of the rectus abdominalis. Effort of nature 
to protect the part. 



GLANDS — THE LIVER 127 



CHAPTER V. 

GLANDS— THE LIVER. 

The liver by virtue of its development is a part of the 
digestive tract. It corresponds to the intestinal glands 
in that it manufactures bile, which assists in the prepar- 
ation and absorption of fats. 

By virtue of the large amount of blood brought to 
the organ, containing products of carbohydrate and pro- 
teid digestion, it is further an organ of great metabolic 
power, acting as a reservoir and a refinery. 

On account of the substances brought to it from the 
body at large through the hepatic artery, it is an organ 
of excretion. 

As a whole on account of the great vascularity and 
relation of it to the heart, stomach, pancreas and spleen, 
there is little wonder that slight changes in the natural 
working of any of these organs is marked by great he- 
patic disorder. On the other hand is it to be wondered 
at, if the organ which contains one-quarter of the total 
quantity of blood in the body, should fail to properly act 
upon that blood, that the heart would suffer? 

Here again we find that close relation of the or- 
gans; the slight alteration in one being made manifest 
in the others. In seeking the explanation of changes in 
the liver or of symptoms which appear to be entirely due 
to pathalogic changes in the organ (liver), we are often 
led astray from a primarily damaged heart and a disor- 
dered stomach or vice versa. 



128 APPLIED PHYSIOLOGY 

The chief functions assigned to the liver are, secre- 
tory power of manufacturing bile and glycogen, and the 
excretion of urea, which it forms from ammonia com- 
pounds resulting from nitrogenous katabolism in the 
various parts of the body. As soon as the deflux of portal 
blood is impaired by pathological processes in the liver, 
engorgement occurs in the contributing branches of the 
stomach, etc. 

The blood also gradually advances into the communi- 
cating ducts which exists between the portal vein and 
the inferior vena cava. 

Such anastomoses are : 

i — Superior gastric with diaphragmatic and in- 
ferior oesophageal veins. 
2 — Hemorrhoidal plexus. 

3 — Accessory portal branch with the vena cava. 

In portal obstruction the blood flows into these com- 
munications, thus returns to the heart, evading the liver. 

Hemorrhoids and caput medusae are due to disten- 
tion of these veins. 

Icterus — 

When the pressure rises in the bile ducts, or falls 
in the blood vessels, alteration in the flow of bile 
must take place ; it passes in the direction of the 
least resistance, which is into the blood vessels. 
The latest experiments show that in such cases 
the bile passes into the lymph spaces (not the 
blood capillaries), and from thence into the blood 
by way of the thoracic duct. 



GLANDS — THE LIVER 129 

Obstructive Icterus — 

This form depends upon a total of partial occlusion 
of the bile ducts. Some or all of the bile is 
absorbed and stains the various tissues, e. g., 

the skin and the mucous membranes. It gives a 
tint varying from, a pale yellow to a dark brown 
or black. The shades are due to the long dura- 
tion of the staining. The bile pigment occurs 
in the urine and sweat. May stain the linen. 

Causes : Catarrhal or other obstruction of the biliary 
passages. 

Liver changes as cirrhosis, abscess, carcinoma, etc. 

The feces are of a light color, due to a lack of pig- 
ment. Much fat in the stools is due to improper 
emulsification and absorption of the same. 

The foul odor of the stools is due to albuminous 
bodies not being as freely absorbed as normally, 
on account of being enclosed in fat ; hence putre- 
faction and odor. It is to be remembered that 
this is the explanation of odor only when, on ac- 
count of disease of the liver or pancreas, the fat 
interferes with the absorption of the albuminous 
bodies. 

Non-Obstructive— 

This form is improperly understood. In it the feces 
are of normal color. 

i — Icterus neonatorum — Theory : the bilirubin is ab- 
sorbed from the meconium instead of being stored 
up in the liver for further use, and it escapes 



130 APPLIED PHYSIOLOGY 

into the general circulation by way of the ductus 
aurantii. 

2 — Infectious diseases — Icterus is seen in pneumonia, 
pyaemic and other infectious diseases. The ex- 
planation is not always clear. It seems probable 
that a parenchymatous degeneration of the liver 
without any biliary obstruction may be the cause 
of the reabsorption icterus in these cases. 

Hematogenous Icterus — 

A term formerly used. In blood alterations from 
drugs the yellow pigment is formed from the 
haemoglobin of the corpuscles, changed into bile 
pigment, but within the liver, not in circulation 
outside of the liver. This accumulates and part 
is absorbed. 

Bile Acids — 

The genesis of bile acids has not yet been deter- 
mined. 

Bile acids may cause: 

Albuminuria by irritation of the renal epi- 
thelium. 

Pruritis by irritation of the terminal sensory 
endings. 

Decreased blood pressure by toxic paresis of 
the myocardium. 

Slow pulse due to the same cause; also proba- 
bly to the effect upon the vagi centers. The 
slow pulse has been removed by the use of 
atropine. 



GLANDS — THE LIVER 131 

Glycosuria — 

While one of the chief functions of the liver is that 
of converting glucose into glycogen, and storing 
the glycogen until needed, when much of it is 
again reconverted into glucose, still it is not 
known positively whether more sugar is brought 
to the liver than leaves it. A number of sugar 
splitting enzymes have been isolated from the 
liver substance. It has been supposed that at 
least some of them would lessen the amount of 
sugar in the organ. Other liver ferments are 
supposed to convert the glycogen back into 
sugar again. Furthermore it is not known posi- 
tively whether either class of ferments named 
are formed by the liver cells or are formed by 
some other organ as the pancreas and carried 
there by the portal circulation. The best evi- 
dence at the present time is that the liver plays 
but a small part in the destruction of sugar, in 
so far as the production of glycosuria is con- 
cerned, and that the pancreas is the chief organ 
affected. 

Nitrogenous Disturbances — 

In the disintegration of albumin bodies, there occur 
in the tissues various amido-acids (glycocoll, 
leucin, tyrosin, etc.) ; these further produce am- 
monia.. The lactic acid ammonia especially, 
continually flows into the liver, is changed into 
the carbonate of ammonia; later with the with- 
drawal of water the liver cells change it into 



132 APPLIED PHYSIOLOGY 

carbamate of ammonia, and urea. The liver 
action is probably due to a ferment. 

In disease it is shown that liver insufficiency is fol- 
lowed by less urea and more ammonia in the 
urine. It is quite possible that the liver may 
compensate for loss of function in urea forma- 
tion. The liver is not the only organ that forms 
urea, the process of the formation of which is 
not yet fully understood. 

Uric Acid — 

This substance is formed in all tissues from the 
nuclear constituents of disintegrating cells (nu- 
cleins) especially of decaying leucocytes. Nu- 
cleins furnish upon transformation so-called 
xanthin bases, which upon sufficient oxidation 
change into uric acid. 

Cirrhosis of the Liver — 

Atrophic Form — 

Gastric Catarrh — Due to chronic passive hyperaemia 
produced by obstruction of movement of the portal 
blood through the liver. 

Constipation — Due to defective biliary secretion and 
to gastric disturbances, whereby the excessive 
secretion prevents the normal secretion of gas- 
tric juice. 

Nasal, gastric, and oesophageal hemorrhages are due to 
obstruction of the portal blood and free anas- 
tomosis of the portal branches. 

Oedema of the legs — Due to accumulation of ascites, 



GLANDS — THE LIVER 133 

which exercises pressure upon the returning 
blood of the lower extremities. The ascites it- 
self being due to portal obstruction. 

Hemorrhoids, due to the same cause as hemorrhages. 

Urea is generally decreased as a result of actual de- 
struction of hepatic cells. 

Hypertrophic Form — 

Jaundice due to the obstruction of biliary vessels. 

Cholelithiasis — 

Biliary colic — Due to passage of stone through the 
ducts. 

Pain frequently radiates to the shoulder. 
Nausea and vomiting — Due to reflex irritation. 
Jaundice due to biliary obstruction. Occurs in pro- 
longed attacks. 

Collapse with consequent peritonitis and shock. Due 
to perforation. 

PANCREAS. 

The function of the pancreas is to furnish digestive 
juices which have the power of digesting all kinds of 
food. The power exerted by the pancreatic juice is 
greater than the saliva on the carbohydrates and the 
gastric juice on the proteins, while it alone has the 
power to prepare the fats for absorption. Besides the 
digestive function the pancreas furnishes an internal se- 
cretion to the blood. This internal secretion is presumed 
to act chiefly in the destruction of sugar in the body. 

Diseases of the pancreas then will lead to digestive 



134 APPLIED PHYSIOLOGY 

disorders, constitutional disorders as diabetes, and to 
death (pancreatitis). 

A decrease in the amount of indican in the urine is 
seen in diseases of the pancreas. This is due to the 
nitrogenous digestion being incomplete. Those cases of 
pancreatic disease, where constipation may be present 
in which a greater portion of the end products of the 
albuminous bodies are absorbed and pass off in the urine 
giving a greater amount of indican, as is also seen in 
the occlusion of the intestine, e. g. in occlusion of the 
duodenum by a swollen pancreas, making the decrease 
mentioned above, is the more remarkable as a point of 
diagnosis. 

Nervous symptoms — Due frequently to compression 

of the coelic plexus by the enlarged pancreas. 
Reflex inhibition of the cardiac action is due to irri- 
tation of the abdominal sympathetic. This also 
causes attacks of neuralgic pains. 

Jaundice and ascites due to pressure upon the ductus 
communis choledochus and upon the portal vein. 

Fatty stools due to excess of fatty diet, as well as 
failure of emulsification and absorption. 

Glycosuria — Lack of internal secretion, the internal 
ferment which produces destruction of sugar. 

Stenotic murmurs in the abdominal aorta — Due to 
pressure. 

THE SPLEEN. 

As the spleen acts like a large lymphatic gland, in that 
when the amount of debris in the body appears to increase 



GLANDS — THE LIVER 135 

in amount or when there is a great disturbance in the genesis 
of the blood corpuscles, it suddenly and without a great 
effort enlarges to compensate for the increased work. 

On account of the peculiar construction of this organ 
it can be enormously enlarged by blood at times and later 
return to its normal size. 

There are no reliable symptoms of value in diagnosis in 
affection of the spleen except the palpable enlargement. 

Outside of tumors the enlargement must be differen- 
tiated from that of engorgement or that of simple hyper- 
plasia. 

Enlargement of the spleen may be due to : 
Engorgement seen in cirrhosis of the liver. 
Unilocular ecchinoccus hepatitis (90%) of cases. 
Hyperaemia of the liver.. 
Emphysema of the lungs. 
Cardiac affections. 

These, like other conditions, are due to passive con- 
gestion. 

It is always necessary that in order to make a positive 
diagnosis of congestion of the spleen due to stasis from the 
vena cava that the liver be found in a state of passive hyper- 
aemia. 

Not all enlargements of the spleen are due to engorge- 
ment when the liver is enlarged. Hypertrophic cirrhosis 
of the liver causes a splenic enlargement due to prolifera- 
tion of connective tissue. 

Amyloid liver causes an amyloid enlargement of the 
spleen, or rather they are both a part of the same process. 



136 APPLIED PHYSIOLOGY 

Acute yellow atrophy and abscess of the liver do not 
always have an associated enlargement of the spleen ; when 
so it is due to a hyperplasia, caused by the infection con- 
nected therewith. 

Malaria has splenic enlargement associated with anemia. 

Leukaemia — Eventually produces enlargement of the 
spleen, which is a true hyperplasia. 

A dislocated spleen enlarges for some reason, or a nor- 
mally located enlarged spleen becomes heavier and is apt to 
descend and float. 

THE THYROID. 

Disease of the thyroid gland is quite common. The 
cause of the diseases are not known. The symptoms pre- 
sented are due to several causes : 

(a) Lack of thyroid secretion or oversecretion of 
the thyroid. 

(b) Nervous disturbances due to effect of pres- 
sure on the sympathetic nerves and to toxins 
acting on the nervous system. These toxins 
are presumed to be present on account of their 
not being destroyed by certain products of the 
thyroid gland. 

(c) Disturbances of the circulation ; chiefly pres- 
sure on the sympathetic and toxic. 

We know that complete removal of the thyroids with 
the parathyroids will produce death. Also that a large por- 
tion of the gland may be removed with no bad effect. Re- 
moval of the parathyroids is followed by tetany, while re- 
moval of the thyroids by a condition, called myxoedema. 



GLANDS — THE LIVER 137 

There is presumed to be a close relation between the 
thyroids and the metabolism of the digestive products, par- 
ticularly the nitrogenous. Believed by some that the involv- 
ment of the thyroid is always secondary to gastro-intestinal 
disturbances ; further that the toxins present in thyroid dis- 
ease are of gastro-intestinal origin. 

Absence of the thyroid secretion in children present the 
condition, called cretinism. 

It appears to be conclusive that the product of thyroid 
activity is an iodine organic substance. 

THE ADRENALS. 

Addison's disease should be considered as an affection 
of the splanchnic nervous system in general. It might be 
caused by changes in the spinal cord, in the splanchnic nerve 
itself, in the coelic ganglion, or in the terminal organ of the 
adrenal bodies. ( Neusser) . 

Pigmentation of the skin in Addison's disease cannot at 
all be directly connected with the adrenal bodies, although 
it is associated. 

Pigmentation is supposed to be due to disturbance of 
the sympathetic nerve. 

Complete destruction of one adrenal proves harmless 
to man, as it does to animals. Secretion of the adrenals has 
a function not borne by that of any other organ. The active 
substance of these glands causes stimulation of most muscu- 
lar fibers supplied by the vaso-motor system, being similar 
in its action to that of the constrictors. The action is noted 
where the sympathetic fibers are found. When bronzing 



138 APPLIED PHYSIOLOGY 

occurs both adrenals are disturbed functionally or are dis- 
eased. 

Depression — Mental and physical. 

Digestive disturbances. 

THE PERITONEUM. 

The peritoneum is a serous membrane, so richly sup- 
plied with blood vessels and lymphatics, by means of which 
it is very close in communication with the pelvic, abdominal 
and thoracic organs, and it plays a very important role in 
maintaining the natural resistance of the body. On account 
of this close association it is especially liable to become 
involved from the disease of the various organs mentioned. 
Never diagnose peritonitis unless we succeed positively in 
determining the cause. — (Leube). 

The peritoneum may be invaded in four ways : 

i — From the general circulation, the so-called 

hematogenous peritonitis. 
2 — By bacterial invasion from neighboring organs 

without perforation or infection by continuity., 

3 — Following perforation of any of the hollow 
viscera. 

4 — Infection from penetrating wounds or ab- 
dominal operations not perforating the viscera. 
—(Abbe). 

Pain is due to the inflammation and the severity is com- 
mensurate in extent with that process. 

Dorsal decubitus — Due to effort to relieve tenderness. 



GIvANDS — THE LIVER 139 



Abdominal distention — Due to paralysis of the muscu- 
lar coat of the bowel. 

Vomiting — Reflex, excited by the inflammation. 

Clammy skin, feeble pulse, etc. — Due to shock and 
collapse. 

Obliterated liver dullness — Due to effusion and extreme 
tympany. 

Increased peristalsis — Due to increased irritation of in- 
testines. 

Diminished peristalsis, ileus paralyticus — Due to par- 
alysis of the intestines. 

Permanent high position of the diaphragm — Due to 
dilatation of the intestine and accumulation of 
larger quantities of exudate in the peritoneum, as 
well as to the violent pains upon movement of the 
diaphragm. 

ASCITES. 

Physical signs vary with the amount of fluid. 

The abdomen is more or less distended. Skin free from 
folds, smooth and glistening. Venous swelling on abdominal 
walls in the region of the epigastric veins. Due to the deflux 
of blood through the inferior vena cava. 

Oedema of the lower extremity — Due to the same cause. 

Caput medusae — A deflux of portal vein blood. 

Percussion — Dullness where fluid touches the wall. 

When the patient is raised in the recumbent position 
percussion tympany is noticed over a small area over the 
kidney towards the axillary line, due to the fact that the 



140 APPLIED PHYSIOLOGY 

ascending and descending colon posteriorly are not covered 
by peritoneum, hence no transudate can be present there. 

In order to demonstrate the above conditions the fluid 
should amount to from one to two liters. 

Ascites may be due to pressure on blood vessels or other 
obstruction of blood or to inflammatory exudate. 

Forms and causes of oedema — 

i — Ascites alone or with oedema of the legs later. 
These due to engorgement of the portal vein, 
etc. Seen in liver affections, abdominal tumors, 
etc. 

2 — Ascites, oedema of the legs, hydrothorax, cy- 
anosis, etc. Due to impairment of the blood 
circulation ; seen in cardiac, pulmonary or pleu- 
ral affections. 

3 — As seen in the last form, but without cyanosis 
and with pallor. Due to pathological permeabil- 
ity of vascular walls and of deficient absorba- 
bility of the peritoneum. Seen in Bright's dis- 
ease, cachectic conditions, fevers, etc. 



TEMPERATURE AND FEVER 141 

CHAPTER VI. 

TEMPERATURE AND FEVER. 

The heat of the body as produced in conjunction with 
the enery, arises chiefly from the processes of metabolism. 
This is slightly affected by such conditions as age, exercise, 
climate, food, and to a greater extent by the time of the 
day; while such conditions as emotions, etc., seen best in 
hysteria, will frequently cause a non-pathological rise of 
temperature of several degrees. 

Man, a warm-blooded animal, has certain prominent 
heat regulators. His temperature varies but little, whether 
he be in the torrid zone or the icy fields of Greenland. On 
the other hand, cold-blooded animals have a temperature 
which is variable with the atmosphere in which they live. 

In the metabolism of the food products and of the 
body tissues we find that almost all of the heat and energy 
is derived from the breaking down, or as it is generally 
called, katabolic processes, while the synthetic processes fur- 
nish but a small amount of heat. 

The maintenance of the temperature in man depends 
upon the chemical changes continually taking place. The 
oxygen taken in chiefly through the respiratory tract unites 
with the hydrogen and the carbon, and oxidation of these 
products takes place. In man we find that in order that 
there may be a compensation for the amount of heat pro- 
duced, compared with that given off, there is an arrangement 
whereby connection is made between the peripheral and 



142 APPLIED PHYSIOLOGY 

central parts of the nervous system which so regulates the 
normal condition, income and expenditure of heat of the 
body, that the daily variation in health under all conditions 
is rarely over two degrees and usually much less. 

This arrangement by the nervous system is connected 
peripherally to the blood vessels on the one hand, and to 
such structures as the skin, glands, mucous membranes, 
etc., peripherally on the other; while centrally, through 
which impulses must pass which regulate the changes in the 
blood supply to the part, we find the higher centers as the 
important factors, the chief of which are presumed to be 
located in the cerebrum. 

The expenditure of the heat is principally due to the 

loss through the skin by radiation, evaporation and conduc- 
tion. In the production of heat we find that the fats en- 
tirely, the carbohydrates almost entirely, and to a much less 
degree the proteins will form as much heat when burned in 
the body as when combustion takes place outside of the 
body itself. 

We refer here to the katabolism of the respective classes 
of tissues, not to the breaking up of the foods themselves. 
The principal product of protein metabolism, urea, is still 
capable of suffering further combustion after it has left the 
body. 

It is necessary to know the amount of heat which can 
be produced by certain forms of diet, and the amount of 
each class of food that should be taken daily. The value, as 
set upon the different foods is based chiefly upon the amount 
of heat which these will respectively produce ; and, as given 
for the number of kilo calories required by an individual tak- 



TEMPERATURE AND FEVER 143 

ing moderate exercise for 24 hours, is about twenty-seven 
hundred. The relative value of each, per gram, is : proteins, 
4.1; carbohydrates, 4.1, and fats, 9.3 calories. The amount 
of exercise taken by an individual must necessarily require a 
variation in the number of calories demanded. In health, 
and also in disease, we see that to a great extent the maxi- 
mum amount of heat is produced in the body in those parts 
where we see the greatest activity, where there is the greatest 
amount of katabolic change ; that is, in the muscles. Follow- 
ing these we find the liver, alimentary canal, glands, brain, 
etc., in order. 

While it is interesting to know the amount of heat pro- 
duced within the body, also the amount which may be ex- 
pended by the different avenues of escape, for our under- 
standing of fever, or in many cases, as we shall call it, ele- 
vation of temperature, we must look carefully to the com- 
pensation or compensatory apparatus which maintains the 
equilibrium so nicely and constantly throughout life. Even 
in fever we find that the effort is still made to maintain this 
equilibrium. 

It is now known that the metabolism of certain products 
of the body, for example, protein metabolism, depends al- 
most entirely upon the amount of protein food eaten; in 
other words, the amount of urea which is excreted, formed 
from the breaking down and oxidation of the protein tissues 
and products circulating in the body is directly proportional 
to the amount of protein food taken into the body. 

The normal excretion of urea depends upon the 
amounts of protein food taken by the person. This does 
not hold true with all protein products, for it has lately 



144 APPLIED PHYSIOLOGY 

been shown that the amount of creatinin excreted de- 
pends to a large extent upon the weight of the person 
regardless of the kind and quantity of food taken at the 
time. So rapid and so effective is the control of tem- 
perature by the nervous system that section or stimula- 
tion of certain nerves will cause a rapid rise or fall, as the 
case may be, of the temperature of the parts supplied. 
Stimulation of the corpus striatum, optic thalamus, sep- 
tum lucidum, caudate nucleus and corpus callosum have 
been followed, in the hands of many experimenters, with 
a rise of temperature. Traumatic lesions of the brain 
and cord are quite often followed by changes in the body 
temperature, entirely independent of the metabolism of 
the body at. that time, the condition being, in these cases, 
a change in the equilibrium of the income and expendi- 
ture. 

In the elevated temperature we find that both the 
amount of oxygen absorbed and of carbon dioxide elim- 
inated are increased. There is an alteration of the re- 
spiratory quotient. Destruction of the nerve endings or 
section of the medulla oblongata will produce a con- 
dition in man which corresponds to that of cold-blooded 
animals ; that is, after such destruction heat may be 
added to, or taken from the body, showing that the ar- 
rangement for the normal maintenance of bodily tem- 
perature is not intact; it will soon be possible to demon- 
strate that in many conditions in man where an elevation 
of temperature may exist, there is partial and temporary 
inhibition of the regulating factors which corresponds 
closely to the results experimentally produced. 



TEMPERATURE AND FEVER 145 

The normal connection is between the skin and the 
muscles, and it is probable that in these experiments 
and in the conditions which present themselves to us, 
the inhibition is at one of these places mentioned; that 
is, there has been some interference in the normal reflex 
arcs, the regulating centers being much influenced by 
impulses from the skin ; the efferent nerves may be either 
augmentative or inhibitory. 

The effect of heat on the vital centers, as seen in com- 
mon fevers, is to cause activity of the vital organs and 
great increase of metabolism in many parts. The tem- 
perature of the body will respond to a certain extent 
to excessive heat or cold. An approximate estimate of the 
quantity of heat produced by an organism may be made 
from the amount of oxygen consumed, and it is well that we 
remember this fact, for in those conditions which we shall 
mention later where we find that there is not a true 
pathological condition present there is no evidence what- 
ever of the amount of oxygen absorbed being increased. 
It is stated by one writer that one-seventh of the heat 
of the body is produced by the union of oxygen and 
hemoglobm, forming the chemical compound oxyhemo- 
globin. 

After a profuse acute hemorrhage the temperature 
may fall from .5 to 2 C, which may be due to the re- 
duction of oxidation processes in the tissues. Poisons, 
including chloroform, alcohol, etc., and such drugs as 
quinine, probably furnish less molecular decomposition. 
In the anesthetics, this diminished molecular decompo- 
sition is probably in the nerve. Strychnine, by increased 



146 APPLIED PHYSIOLOGY 

molecular activity, causes a rise in temperature, most 
marked in the convulsions of strychnine poisoning. 

HEAT REGULATION. 

The body may suffer a range of temperature in dis- 
ease from 22 to 44.65 C. Irritation of the peripheral 
nerves is normally due, as seen in the skin, to thermic 
stimulation In the intestines and digestive glands the stimu- 
lation is mechanical or chemical, all being reflex in nature, 
and acting centrally on the regulating heat centers. These 
known physiological conditions explain the non-patho- 
logical elevation of temperature seen in the puerperium 
dentition, intestinal irritation, nervous conditions, etc. If 
the provision be made that with increased heat pro- 
duction, heat dissipation shall also take place, there can 
be no elevation of temperature or accumulation of heat. 
According to the Leibermeister school, heat regulation 
is placed upon a higher level during the febrile process. 
Increased heat production can be attributed only in the 
smallest part to the transformation of increased circula- 
tory activity into heat, but in the largest part is depend- 
ent on the heat generated in the process of combus- 
tion. In many diseases this is quite apparent, for though 
the patient may consume but a small amount of food 
daily, and consequently the products of the same cir- 
culating in the body would be relatively reduced, yet 
the products of metabolism, as evidenced by the heat 
generated, by the constituents of the urine, and, lastly, 
by the emaciation of the patient herself, show active 
oxidation processes are taking place. 



TEMPERATURE AND FEVER 147 

Subnormal Temperature — In some cases we find 
that this may be due to the excessive loss of heat ; in others, 
the high elevation of temperature, such as may occur 
after catherization or with the passage of a gallstone 
through the bile duct, is a temporary retention of heat, 
in both cases the amount produced being the results 
taking place through the reflex action of the vasomotor 
centers. 

Antipyretics — According to many, antipyretics acts 
by restoring heat regulation to a lower level. Quinine 
acts in the reduction of temperature by limiting heat 
production. According to others, the antipyretics act 
principally in the increase of heat dissipation through 
the dilatation of the blood vessels, while heat production 
is but little affected. 

Ziegler states that the characteristic sign of fever 
is an increased bodily temperature, but accompanying 
it there are other symptoms, especially an increase in 
the pulse rate, disturbance in the distribution of the 
blood, changes in the gaseous interchange within the 
lungs, and also in the urinary secretion ; there is usually, 
but not necessarily, a subjective feeling of illness. 

The Cause of Fever is not known with certainty, 
yet this much can be said, that fever is most frequently 
the result of the entrance, of harmful agents into the 
fluids of the body. It is probable that the entrance of 
parasites and their multiplication within the body causes 
an increased tissue destruction, either directly or through 
the production of unformed ferments; and at the same 
time substances are produced which act as poisons upon 



148 APPLIED PHYSIOLOGY 

the central nervous system. The action of the poisons 
may be assumed to be such that, on the one hand, ac- 
tivity of muscles and glands, and consequently heat pro- 
ducing metabolism is increased ; while on the other hand, 
through the diminution and disturbed function of the 
nerves governing sweating, as well as those of the vaso- 
motors, the heat dispersion falls behind the heat pro- 
duction. Further, though the organism makes an at- 
tempt to regulate the temperature, yet it is no longer 
able to maintain it at a normal level, because of the dis- 
turbance of the regulating apparatus. 

What share in the increase in the body temperature 
is due to the direct action of bacteria and of ferments 
of the bile, and what share is due to the increase of meta- 
bolism through the stimulation of the nerves as well 
as the disturbance of heat dissipation, cannot at present 
be determined. Lazarus-Barlow states that heat may 
be developed in the breaking down of food products, 
as well as in oxidation. The amount of heat produced 
by the heart in twenty-four hours is equal to from one 
hundred to three hundred kilo calories. The direct 
action between the production and the loss of heat is 
by the blood. 

It has been shown that water at a temperature of 
98.4 F., when held in the mouth for two minutes, will 
cause a rise of temperature of .5° F. When the body is 
placed in a bath at 112 F. for twelve minutes, the tem- 
perature rises from 98.2 F. to 103. 2 F., with faintness, 
palpitation, etc. The symptoms are those associated 



TEMPERATURE AND FEVER 149 

with great exercise, or the mechanisms, presiding over 
heat loss. They cannot justly be called pathologic. 

Temperature may return to normal or below normal 
in about an hour. There has been both a diminution of 
heat loss and heat added from without in the above in- 
stance. Hyperthermia, or an elevation of temperature 
above normal, without the associated conditions which 
produce fever, is not pathological unless we should have 
the conditions existing for at least a number of hours, 
and being evidenced by changes in tissue oxidation. 
Hyperthermia may become pathologic when we have in- 
creased heat production, diminished loss, and the actual 
addition of heat to the body. Such conditions as hys- 
teria, urethral fever, teething, indigestion, constipation 
and many peripheral irritations we find classed as fevers, 
or have associated fever as a symptom. In most of 
these, or at least many times, the elevation of tempera- 
ture is the principal recognized sign of any disturbance 
and should be called hyperthermia. 

It is most likely that in these cases, as is plainly 
evidenced in hysterical women, the heat regulating cen- 
ter is developed to a lower degree than in the more 
normal individuals. On the other hand, hypothermia 
or fall of temperature may be due simply to exposure to 
low temperature. It is a common condition in many 
diseases, as nephritis, pulmonary diseases, cardiac and 
nervous diseases, and starvation, and from the use of 
drugs. The drugs act either by dilatation of the vessels, 
lowering of metabolism, interference with the heat cen- 
ters, or production of heat. True fever, or pyrexia, con- 



150 APPLIED PHYSIOLOGY 

sists of increased temperature, altered metabolism, etc. 
The rapid changes produced by the temperature are seen 
distinctly in the exfoliation of the tonsrue, the altered 
glandular secretions, and the reaction of the blood ; when 
viewed pathologically, by cloudy swelling, fatty degen- 
eration, etc., of the vital organs. 

In the fever of malaria, elevation of temperature is 
seen with the appearance of microorganisms in the blood, 
acting either mechanically, by the poisons formed by 
the Plasmodium, or the direct changes to which they 
may give rise in the blood and tissues. 

In diphtheria, the bacilli are absent, as a rule, from 
the blood ; the conditions being produced by the products 
of the organisms themselves. 

In health, antipyretics produce no effect. In malaria, 
quinine acts directly upon the microorganisms. Anti- 
pyrin alters the conditions of the blood vessels in the 
skin, increases the heat loss, and acts upon the cerebral 
centers which prevent the loss of heat. 

It is entirely theoretical how the equilibrium is main- 
tained. One school claims a thermotactic mechanism 
exists, which, in fevers is set high, but behaves as nor- 
mal. Another school claims that the thermotactic center 
is set as in health but behaves abnormally, and that the dis- 
turbance is due largely to a thermolytic center which 
behaves abnormally also. Others, yet, claim the exis- 
tence of thermotactic, thermolytic, and thermogenetic 
centers. If the first of these is deranged, the tempera- 
ture is irregular. If the latter two are deranged, fever 
exists. If all three are deranged, there is an irregular 
rising temperature. 



THE KIDNEY AND URINE 151 

CHAPTER VII. 

THE KIDNEY AND URINE. 

Excretions from the kidneys are those substances 
which are formed by the activity of glandular structures 
as well as products of tissue metabolism, all of which are 
brought by the blood to the kidneys. These excretory 
organs discharge their products and they are soon car- 
ried from the body. The composition of true excretions 
; s such that in a general way the substances contained 
in them are found in the blood brought to the glands in 
a similar nature, but in different proportions from that 
of the excretions. The principal organs provided in the 
body for removing waste products from the blood are 
the kidneys; while we find that the skin, lungs, alimen- 
tary canal, liver, etc., have as a part of their function 
that of excretion. The kidneys are so constructed and 
related to the other parts of the body that the action of 
the heart, the condition of the blood vessels and the 
quality and quantity of the blood circulating through 
them influences much the permanency of function and 
activity of these glands. In regard to the substances 
discharged we frequently find that when the kidneys 
are not able to properly perform their function, that a 
part at least of the work of removing the waste products 
-is done by the glandular activity t of the skin and intes- 
tinal canal. The compensatory arrangement is seen to 
act in the same way when the skin is prevented from 



152 APPLIED PHYSIOLOGY 

performing its normal function, by the kidneys doing 
extra work. 

The parenchyma or functionating part of the kidney 
consists essentially of the glomeruli with the uriniferous 
tubules and the blood vessels connected with them. On 
account of the sudden termination of the small afferent 
arteries breaking up into capillaries in the glomeruli, the 
efferent vessel from the glomeruli being smaller than the 
afferent, and for the reason that this breaks up into a 
plexus of capillaries about the convoluted tubules, it is 
presumed that the processes of filtration and osmosis 
play an important part in the formation of the urine. 

But it is rather on account of this arrangement of 
the blood vessels that the blood pressure in the kidneys 
is more constantly maintained at a fixed level, and the 
blood is brought more directly in contact with the cells 
of the glomeruli and the tubules. 

Secretion of Urine — 

The cells covering the glomeruli give out water and 
salts by a true process of secretion, those of the convo- 
luted tubules and of the wide parts of Henle's loop 
secrete the specific constituents of the urine and water. 
(Theory of Bowman and Heidenhain as expressed by 
Tigerstedt). 

Composition of Urine — 

Water 960, solids 40 parts per 1,000. 

1 — Urea — Daily excretion depends upon the sup- 
ply of protein food. 



THE KIDNEY AND URINE 153 

Normally about 2% or 24-35 grammes in 24 
hours. 

It is the chief evidence of N. metabolism. 

2 — Uric Acid — Small quantities found in the 
urine of man. 

This is a di-basic acid. In urine, uric acid 
probably occurs as monosodium urate, which 
is held in solution as di-sodium phosphate. 
It is derived from the purin bases. 

3 — Hippuric Acid — Occurs chiefly after the ad- 
ministration of benzoic acid and after eating 
certain food (fruits). It has no diagnostic 
significance. 

4 — Creatinin. 

5 — Inorganic Salts — The urine contains certain 
inorganic salts, especially the chlorides of 
potassium and sodium, the phosphates of K., 
Na., Mg., and Ca., also the sulphates of some 
of these metals and several salts of aromatic, 
ethereal sulphuric acid. These salts are gen- 
erally tested for by the detection of the cor- 
responding acidulous ions. 

Chlorides — 

The daily amount is from 10 to 15 grammes. 
Increased — After muscular exercise. 

After taking much food or drink. 
During absorption of exudates. 
In acute Bright's disease, diabetes insipi- 
dus, and ague after a chill. 



154 APPLIED PHYSIOLOGY 

Diminished — In all acute fevers, especially pneu- 
monia (increased after the crisis). 
During the formation of exudates and 
dropsies. 

In chronic nephritis, certain dyspepsias, 
diarrhoea, cholera and typhoid. 
Phosphates — 

Daily amount is from two to four grammes. 

The ratio of phosphoric acid is to urea, as about i 
to 10 in health. 

Increased after mental work and nervous conditions. 

After muscular exercise, meat diet, copious drinking. 

Some diseases of bones, diabetes and some fevers. 

Sulphates — 

Daily amount of sulphuric acid 1.5 to 5 grammes. 

Increased in meat diet, prolonged exercises, fevers, 
rheumatism, pneumonia, delirium tremens, cere- 
bral meningitis. 

Diminished — In vegetable diet (usually). 

Nephritis, chlorosis, and chronic diseases gener- 
ally. 

Ethereal sulphates are increased after a vegetable 
diet, and from putrefaction of the proteins in 
the intestine. (Bartley.) 

6 — Oxalic Acid — Calcium-oxalate crystals are 
permanent in alkaline urine. They may be 
formed in either acid or alkaline urines. 
A few crystals have no clinical significance. 



THE KIDNEY AND URINE 155 

They greatly increase after eating of toma- 
toes, grapes, apples or honey, also after tak- 
ing senna, squills or rhubarb. 

Frequently seen during the incomplete oxi- 
dation of the carbohydrates in the body. At 
times excessive fermentation in the intestine. 
Long continued excretion of the excess of 
the oxalates may irritate the kidney and cause 
albuminuria and lead to the formation of a 
calculus. 

7 — Indican — Indoxyl-potassium-sulphate. Formed 
from nitrogenous substances absorbed from the 
intestines. Normally a small amount is present. 

8 — Ammonia. 

9 — Pigments-Urobilin, urochrome and ureory- 
thrin. 

io — Reducing substances and proteins in small 
quantities. 

The reducing power of normal urine corre- 
sponds to 0.15 to 0.6% solution of dextrose 
(Tigerstedt). 

The Daily Amount of Urine — 

Normally 1200 C. C.-1600 C. C. 

Quantity favored by quantity of water ingested. 

Amount varies with prespiration, diarrhoea and 
vomiting. 

Polyuria means an increased amount ; oliguria a di- 
minished amount. 



156 APPLIED PHYSIOLOGY 

The amount in diseased conditions depends upon — 
i — The condition of the secreting renal paren- 
chyma. 

2 — The rapidity of the blood current in the kid- 
ney and the blood pressure. 

3 — Upon the percentage of diuretic substances 
in the blood. 

Diuretics — 

Anything which increases the amount of blood flow 
increases the amount of urine. To the natural 
diuretic substances belong: urea, sodium chlor- 
ide, grape sugar, etc. They abstract water from 
the tissues, increase the osmotic pressure of the 
blood, and finally produce a consequent dilata- 
tion of the renal vessels. 

A second class of diuretics act by a stimulating ef- 
fect upon the renal epithelium. 

If the body is poor in NaCl and certain diuretics are 
given there is no increase in the NaCl, although the 
amount of urine is much increased. If the 
body has plenty of NaCl then with diuresis this 
salt will be increased. (Tigerstedt). 

To alter the amount of blood in the kidneys appre- 
ciably both kidneys must be diseased. 

The Amount of Urine Is Diminished In — 

Diseases of the heart and lungs — Depends upon the 
slowing of the renal circulation, when passive 
congestion exists. 



THE KIDNEY AND URINE 157 

Diseases with diarrhoea, vomiting, and sweating. 

A diminished amount of urine, due to diminished 
flow of blood through the kidney on account of 
vaso-constriction may be seen in — 

Asphyxia. 

Strychnia poisoning. 

Painful stimulation of sensory nerves. 

A diminished amount of urine may be produced by 
low pressure, due to a general vaso-dilatation 
of the skin vessels which depresses the secre- 
tory function of the kidneys, the amount of 
blood flowing through them is also lessened. 

The Amount of Urine Is Increased In — 

Convalescence from typhoid, and pneumonia, also 
after diuretics, including stimulents. It is also 
increased after convulsions — especially in hy- 
steria, the so-called urina spastica, and after 
attacks of angina pectoris, probably due to vaso- 
motor disturbances. Polyuria is also present 
in diabetes mellitus — depends upon the quanti- 
tative and qualitative variations in substances 
eliminated. 

Acute nephritis shows less urine — Due to : 

Diminished velocity of current. 

Diminished blood pressure. These being caused 
by inflammation or swelling and desquamation 
of the epithelium of the glomeruli. 

Chronic nephritis, shows more urine. Seems to Sahli 



158 APPLIED PHYSIOLOGY 

to be compensatory rather than due to increased 
blood pressure. 
In regard to the quantity of urine, the so-called 
parenchymatous nephritis resembles sometimes 
acute nephritis and sometimes the contracted 
kidney. A similar variation in amount is seen 
in amyloid kidney. 

MICTURITION. 

The desire to urinate is aroused by fullness of the 
bladder. 

The flow can be voluntarily suppressed by contraction 
of the outer and probably inner sphincters. 

Normal urine does not undergo any visible changes 
in quantity in the bladder either by diffusion or absorp- 
tion. 

Frequency of Urination — 

Generally corresponds to the amount of urine se- 
creted. 

It is influenced by inflammations of the bladder, ure- 
thra, pelvis of kidney. 

Frequency depends upon reflex stimulation of the 
bladder. 

Frequency is influenced by diseases of the spinal 
cord and brain. 

May be and often is caused by an abnormality in 
the composition of the urine, as, too concen- 
trated urine, excess of urea, presence of irritat- 
ing substances. 



THE KIDNEY AND URINE 159 

Incontinence of Urine — 

Due to either contraction of the bladder muscle or 
to the relaxation of the sphincters. If both are 
paralyzed it leads to retention plus incontinence 
(distention of the bladder with constant drib- 
bling). 

May be the result of conditions which interfere with 
the normal voluntary control from the brain. 
All forms of coma — sunstroke, shock, and bac- 
terial poisons. 

The above annual conscious cerebral activity. 

Injuries and tumors of the cord, and many lesions 
of the cord as transverse myelitis, spinal menin- 
gitis, and locomotor ataxia. 

In locomotor ataxia there is loss of power in the 
sphincter due to injury or lesion in the cord at 
the third or fourth sacral nerves. The condi- 
tion being that both the expelling and retention 
muscles are paralyzed, the urine accumulates 
and dribbles off. 

The above interfere with the conduction to and from 
the vesical centers in the lumbar segments. 

If the reflex arc is abolished by the same lesion af- 
fecting the centers, total paralysis of the bladder 
with retention and dribbling will result. 

When incontinence is due to local irritation as as- 
carides, vesical calculus, phimosis, cystitis, etc., 
impulses are sent to the cord and the motor 
response is brought through the muscles of ex- 



160 APPLIED PHYSIOLOGY 

pulsion, even when the bladder is not distended. 
During sleep the will power is lost and reflex 
activity is alone in control. 

Retention of Urine — 

Usually depends upon causes outside of the bladder. 

Retention may alternate or co-exist with incontin- 
ence of urine. 

Seen in all forms of coma, typhoid fever, typhoid 
state, peritonitis, hysteria, following parturition, 
in enlarged prostate, irritating urine, stricture 
of the urethra. In locomotor ataxia the im- 
pulses are not recognized, so that the sphincter 
closing the bladder does not relax; these are 
controlled by impulses from the brain and cord. 
Injuries to the spinal cord, destruction of the 
motor centers, and myelitis in the sacral centers 
will cause retention. 

Suppression of Urine — Anuria — 

Seen in — Acute congestion — Less blood circulating in 
the kidneys ; a vaso constriction. 

Hydronephrosis — The pressure of retained urine 
increases, the urinary passages at kidney are 
distended, urinary tubules become oedematous, 
over-filled tubules and swollen cells press 
upon veins and capillaries and diminish their 
size, blood flows less rapidly, hence less urine. 
— (Krehl). 

Irritants — Damage to secreting cells. 



THE KIDNEY AND URINE 161 

Collapse — From draining liquids from the body. 

Shock from injuries. 

Many fevers — Probably from hyperaemia or dis- 
turbed innervation of the kidney. 

If there is dribbling with distention — The lower part 
of the lumbar enlargement of the cord is affected, 
causing paralysis of the sphincters. 



When the lower part of the dorsal and upper part of 
lumbar segments are affected, paralysis of detrusor 
exists ; may have overflow — incontinence. 

Urine of locomotor ataxia different from that of mye- 
litis, trauma, etc; depends upon interference with 
reflexes of the bladder. 

Urine of locomotor ataxia may show — 

Straining before urination. 

Interrupted flow of urine. 

Urination before a person is willing. 

Escape of urine upon laughing. 

Ineffectual effort followed by incontinence. 

Retention. 
Incontinence of urine in children often due to the ex- 
cessive reflex irritability of the walls of the bladder. 

Suppression is often seen in hysteria — Due to disturbed 
innervation ; may be prolonged and provoke 
uraemia. 

To diagnose anuria from malingering, etc., catherterize 
and repeat in three hours. 

Tumors often cause suppression by compression. 



162 APPLIED PHYSIOLOGY 

Specific Gravity — 

Normally for 24 hour 10 15-1020. Usually varies in- 
versely with the amount of the urine. 

Low specific gravity, as beer drinking, 1002. 
High specific gravity, as during perspiration, 1040. 

Specific gravity is influenced by — 

Secreting parenchyma of the kidney. 
Velocity of renal circulation. 
Abnormalities of metabolism. 

Specific gravity in acute nephritis is high because the 
amount secreted is small (inversely as the amount). 

In chronic interstitial nephritis sp. gr. is low due to 
large quantity of urine. 

Diabetes mellitus — Sp. gr. is high, much urine, but has 
the presence of sugar. 

In some cachectic conditions there is a low sp. gr. due 
to little urine, from diminished metabolism, with 
little ingestion of water. 

Color of Urine — 

Normally it presents different shades of yellow. 

The higher the sp. gr. the deeper the color. 

Generally pale when the quantity of urine is large. 

Haematuria and haemoglobinuria, urine is dark, due to 
haemoglobin. 

Jaundice, a dark yellow to black from bile pigments. 

Melanotic tumor, dark brown to black — Due to melanin. 

Melanin in urine comes from the chromogen "me- 



THE KIDNEY AND URINE 163 

lanogen," which is present in such urine and becomes 
"melanin." 

Intestinal disturbances, dark brown — Due to excess of 
indican. 

Drugs, as phenol, salol, coal tar preparations, etc., 
produce a dark color. This dark color should give no 
alarm unless one of these drugs is being used exter- 
nally. Shows absorption. 

Chrysarobin, senna, rhubarb, cascara, etc., may 
give a yellow urine; but it is distinctly red if alkaline. 

Santonin and saffron cause yellow urine. 

Methylene blue causes blue color. 

Turbidity of urine.. A most frequent cause of tur- 
bid urine when not due to mucus, pus, etc., is presence 
of urates in excess. When the urine becomes alka- 
line due to ammoniacal decomposition, urates rapidly 
form. They are not readily soluble in cold urine, but 
disappear on heating. 

Odor of Urine — 

The disagreeable, so-called uriniferous odor depends 
upon bacterial decomposition, either in the tract or 
after being voided. Often called ammoniacal. 

Decomposition of albuminous urine is characteristic. 

Reaction of Urine — 

With phenolphthalein the reaction is always neutral or 
weakly acid. 

A plainly alkaline urine is never seen except in urine 



164 APPLIED PHYSIOLOGY 

which has suffered bacterial decomposition. (Auer- 
bach and Friedenthal). 

Acidity is due to acid sodium phosphate, and to a small 
extent to organic acids. — (Folin). 

Reaction may be alkaline due to: 

Vegetable diet. 

Wine or fruit. 

Alkaline drugs. 

Abnormal condition of the gastric juice.. 

Admixture of alkaline secretions from exudates of 
the urinary tract. 

Rapid absorption of transudates or exudates. 
Alkaline fermentation in the urinary tract. 

Organic acids become oxidized in the body to alkaline 
carbonates. 

Alkalinity due to fixed alkalies is only shown when 
litmus paper is dipped in the urine it becomes 
permanently blue. 

Alkalinity due to volatile alkalies (ammonia) turns blue 
if held above the urine, blue color disappears by 
heating. 

Acid reaction is intensified by a rich proteid diet. 

ALBUMINURIA. 

(a) True or renal, including physiological.. 

(b) False or accidental — That added to urine with pus, 
blood, etc. 

Renal albuminuria — Always due to an abnormal per- 



THE KIDNEY AND URINE 165 

meability of the epithelium, especially that of the 
glomeruli permitting the proteins of the blood to 
pass through. 

Definite pathologic albumin depends upon some affec- 
tion of the renal epithelium as inflammation and 
disturbances of the circulation of the kidneys and 
in the amyloid kidney. 

Renal epitheltum may be damaged sufficiently to cause 
albuminuria by anemia, hydronephrosis, cold baths, fevers, 
etc. 

Febrile albuminuria is rare except in severe infections. 
When the quantity of albumin is great it may be impossible 
to make a diagnosis between it and true nephritis. Appears 
in typhoid at or near the end of the disease. 

Febrile albuminuria is due to weakness of the heart, or 
infection irritating the kidneys, or both. In some cases 
due to nervous causes, when the toxic substances which 
are products of albuminous disintegration formed during 
fever, so act upon the splanchnic nerves and upon the vas- 
cular nerves of the kidney, the irritation causing a narrow- 
ing of the renal artery, there is less urine and albumin 
passes into the glomerulus. 

In typhoid fever there is concentrated urine as another 
cause. 

In acute nephritis albuminuria is due to deficient nutri- 
tion and abnormal permeability. 

In pregnancy, albuminuria is due to changes in the 
blood and to pressure of the uterus upon the renal vessels. 



166 APPLIED PHYSIOLOGY 

Congestion of the Kidney — 

Effect of partial tying of the renal vein is to cause 
a decrease in the amount of urine and presence of 
albumin due to decreased velocity. Engorgement of the 
renal veins is seen mostly with association of a weak 
heart, with a diminished velocity and a decrease of 
blood pressure in the glomerulus, hence less urine. 

If blood is present in urine of an engorged kidney 
it shows almost always a complication of nephritis or 
hemorrhagic infarct. Uraemia will never follow simple 
engorgement because the renal epithelium is not injured 
and after engorgement the kidney is able to show 
greater activity. 

Physiological, Functional, Cyclic, or Intermittent Albu- 
minuria — 

Called by some pathologic — 

Seen in severe muscular exertion, cold baths, mental 

exertion, emotion, menstruation, after certain diet. 

Cause not known. 

Globulins — 

Seem to always accompany serum albumin in the urine. 

No diagnostic significance yet found. 

They are found in urine, especially in catarrhal inflam- 
mations of the bladder, in acute nephritis, and in 
amyloid degenerations of the kidneys. 

These substances are very similar in nature to albumin 
as found, and their appearance seems to be identi- 
cal with albuminuria. 



THE KIDNEY AND URINE 167 

Albumosuria — 

The terms propeptonuria and peptonuaria should be 
considered synonomous. 

Seen alone with albumin in: 

Puerperium. 

Acute yellow atrophy. 

Ulceration of the stomach and intestines. 

Suppurating processes. 

Most febrile conditions. 

Presence of albumose is only significant when no 
albumin is present. 

In albumosuria, albumose is generally found after 
removal of the albumin. 

Presence only of limited diagnostic value. May 
mean deep-seated suppuration. 

A decided albumosuria is a most suggestive condi- 
tion of multiple myeloma or myelogenic osteosarcoma. 

Thought by some that albumoses are formed from 
albumins by chemical processes employed in their re- 
moval. 

Mucin — 

Most mucin of former years is now recognized as 
nucleo-albumin. 

Mucin free from phosphorus, when decomposed, 
produces protein and carbohydrates. Nucleo-albumins 
contain phosphorus ; when decomposed furnish protein 
substances and a group containing phosphorous (nuc- 
leins). For the time being it is justifiable to call mucin- 



168 APPLIED PHYSIOLOGY 

like substances nucleo-albumins, which are both physio- 
logic and pathologic. 

As would be expected, since this substance is the 
product of mucous glands, where they are affected, 
mucin appears, hence we find mucin in catarrhal in- 
flammations of the genito-urinary tract, in irritation of 
the genito-urinary tract without true inflammation as 
well as in the febrile states, especially in the beginning. 

Traces in all urines. 

Nucleo- Album in, pathologic in — 

Inflammations of the genito-urinary tract. 
After irritating drugs. 
Leukemia, etc. 

Blood- 
Blood in urine may come from the kidney or genito- 
urinary passages. 

If blood itself — haematuria. 

If a transudate of haemoglobin — haemoglobinuria. 
Haematuria — Inflammation of the genito-urinary tract, 
new growths, injuries, etc. 

Haemoglobinuria — Certain poisons, malaria, etc. After 
burns there may be periodic haemoglobinuria. 

Carbohydrates — 

In normal urine may find traces of carbohydrates. 
Three are known: Animal gum, dextrose (only by 
Mollisch's test) and isomaltose. 

Mollisch's (alpha-naphthol) test — To i c. c. of 
urine add 2 c. c. of a 10% solution of a-naphthol in 



THE KIDNEY AND URINE 169 

pure methyl or ethyl alcohol. After mixing add an 
excess of H 2 S0 4 . If sugar is present a deep violet 
color, etc. This is a very delicate test. 

Diazzo Reaction — 

Nature of the body giving the reaction is still unknown. 
Reaction may be regarded as indication of a pathologic 

decomposition of proteins. 
Must be considered as a metabolic symptom in certain 

diseases. 

Reaction may be obtained after use of certain drugs. 

It has been considered of diagnostic value in typhoid 
fever.. Seen in severe cases of pulmonary tubercu- 
losis, measles, pyaemia, scarlatina and erysipelas. 

Indican — 

More than a trace indicates absorption of products of 
putrefaction from the intestine ; the amount of in- 
dican is increased in a diet of much meat. 

Seen also in intestinal obstruction, but not in ordinary 
constipation. 

Hematophorphyrin — 

A pigment occasionally found in urine of cases of 
rheumatism, Addison's disease, pericarditis, cirr- 
hosis of the liver and croupous pneumonia. 

Pentose — 

The presence of pentose, a 5 C-atomic sugar in the 
urine, has not been satisfactorily explained. 



170 APPLIED PHYSIOLOGY 

Urates — 

Found in the febrile state. A constant deposit of 
urates in disease of the viscera, entailing progressive 
emaciation, notably liver disease and the so-called wast- 
ing diseases, has been frequently noted.. Excess of 
urates may be seen in functional disorders of the stom- 
ach. They are due to the incomplete transformation 
of the protein foods. 

Fats- 
Present in urine in : 

Chronic parenchymatous nephritis. 

Fatty degeneration of the kidney. 

Phosphorus poisoning. 

Diseases of the pancreas. 

May be physiological during pregnancy. 

Following fractures. 

Acute yellow atrophy of the liver. 

Their presence is explained by the fact that in the 
diseases named there are severe degenerative changes 
of a fatty nature, and the fat enters the blood either on 
account of lack of oxygen to consume same or the 
oxygen may be present in tissues in normal quantity, 
but not sufficient to destroy the fat. 

Pus— 

This substance may be present in the urine, the source 
being either from a free mucous surface, from an 
ulcer or from the tissue substance. The source of 
the pus is to be determined by its admixture with 
blood, mucin and by the symptoms present. 



THE KIDNEY AND URINE 171 

Casts — 

Casts in the urine may be : 

Hyaline. 

Blood. 

Pus. 

Epithelial. 

Granular. 

Fat. 

Bacteria. 

The cause of casts are: 

i — They are due to disintegration of the epithe- 
lium of the renal tubules, the products being 
moulded. 

2 — They consist of a secretion of the morbidly 
irritating epithelium lining the tubules, which 
moulds, 

3 — They consist of the coagulable elements of the 
blood which gains access to the renal tubules 
through the pathological lesions of the tubules, 
and that any free or partly detached products 
of the tubules become entangled in this cogu- 
lated product, assisting to form the moulds of 
the tubules, which subsequently appear in the 
urine as casts. 

The last theory is generally accepted. — (Purdy). 
The presence of bacteria in urine can be explained by 
the diseases of which they are a part. 



172 APPLIED PHYSIOLOGY 



CHAPTER VIII. 

NERVOUS SYSTEM. 

Nerve tissue is the highest developed and most won- 
derful of all the body tissues, especially noticeable in its 
function. With it is connected the transmission of impres- 
sions from the external world to consciousness, and from 
the will back to the external world. The highest faculties 
of the mind, as sensation, consciousness, will and thought, 
have nerve connections. The human nervous system is 
formed by a mass of separate but contiguous nerve cells. 
By its continuity the nervous system connects all other sys- 
tems of the body, conforming to the framework of the 
body its branches extend to all parts. All incoming im- 
pulses must reach the central system. The central nervous 
system, composed of the brain, cord, cranial and spinal 
nerves is frequently stated as distinct and separate from the 
sympathetic nerve system. While at first glance it might 
appear to be so, yet both anatomically and physiologically 
they are closely associated. The nature of the sympathetic 
impulses being modified by the ganglia from which the 
fibers arise. 

NERVOUS SYMPTOMS IN GENERAL. 

In the consideration of symptoms due to nervous dis- 
eases from a physiological standpoint, we have neurosis, or 
a morbid, nervous state, and psychosis, or a morbid, men- 
tal state, the symptoms of which are felt by the patient, or 
noted by the physician. They may be grouped together 



NERVOUS SYSTEM 173 



according to perverted physiological function, when we have 
following group of symptoms : 

i — Mental and cerebral. 

2 — Sensory. 

3 — Motor. 

4 — Reflex. 

5 — Trophic. 

6 — Vasomotor. 

7 — Secretory. 

There are but three ways that the physiological func- 
tions can be perverted — exaggerated, lessened or lost — and 
in a given case we may find one exaggerated, another les- 
sened and still another lost, thus accounting for the multi- 
plicity of symptoms sometimes found. 

The mental symptoms may grade from fixed ideas — 
obscessions, indecisions, phobias, etc., to all grades of in- 
sanity and imbecility. The sensory symptoms have 
various grades of perverted function of the nerves of special 
and general sensation. Motor disturbances present the 
various disorders of motion from tremor to paralysis, etc. 

Physiological Stigmata — 

i — Deficient resistance to nervous and emotional strain. 

2 — Excessive or defective sensibility of the cutaneous 
and special senses. 

3 — Defective speech. 

4 — Perversion of instincts. 

5 — Tremor. 

6 — Nystagmus. 

7 — Tics. 

8 — Atrophy. 



174 APPLIED PHYSIOLOGY 

Mental Deviations — 
i — Egotism. 
2 — Self-consciousness. 
3 — Peculiar sense of personality. 
4 — special aptitudes. 
5 — Emotional and unbalanced individuals. 

Causes That Lead to Nervous Diseases — 

i — Heredity — Children of nervous parents inherit a 

nervous instability. 
2 — Degeneration — as shown by anatomical deviation. 
3 — Age, sex and occupation. 
4 — Habits, climate, mania and shock. 
5 — Inflection, passion and reflex causes. 

Pathological Causes — 

I — Defective development. 

2 — Vascular and blood diseases., 

3 — Inflammation. 

4 — Defective nutrition and functional disorders. 

5 — Degeneration, sclerosis and atrophy. 

6 — Syphilis. 

7 — Tuberculosis. 

8— Tremors. 

9 — Parasites. 

Nerve Injury — 

Slight pressure of short duration may cause tingling 
and numbness of skin, felt in distribution of sensory 
filament of the nerve involved, which, if continued, 
may also cause motor involvement, when we may 



NERVOUS SYSTEM 175 



have a sense of weakness and lack of skilled move- 
ments. 
May have — 

I — Pain at point of injury. 

2 — Pain or disagreeable sensation referred to dis- 
tribution of sensory fibers. 

3 — Anasthesia to all forms of sensation. 

4 — Trophic disturbances. 

5 — Paralysis of muscles supplied by motor fila- 
ments involved. 

These symptoms may vary according to the amount of 
injury to the nerve or nerves. Spasms of muscles 
may sometimes occur. Over-stimulation or stimu- 
lation prolonged may be followed by paralysis, 
motor or sensory. 

NERVE IMPULSES. 

They are divided into those of motion and those of 
sensation in the central system, while in the sym- 
pathetic the function is frequently quite specialized 
in its nature. 

Motor Nerves — 

Motion is associated with efferent or centrifugal im- 
pulses ; signifies an action through changes in the 
muscle through a motor nerve. A simple act of 
motion is seen in the movement of one muscle, 
as closure of the eye. Complex motion is seen 
in the movement of many muscles. Co-ordinated 
movement is the regular action of several muscles 
working together for the same purpose. 



176 APPLIED PHYSIOLOGY 

Efferent impulses are further divided into those : 

(a) For glands, secretory. 

(b) For inhibition, as in the vagus, splanchnics, 
etc. 

(c) For nutritive tone to the part, trophic (?) 
nerves. 

(d) From one center to another as psychical asso- 
ciation fibers in the brain ; they pass to definite 
motor areas. 

Sensory Nerves — 

Those nerves which carry impulses passing to the 
central axis, called afferent or centripetal. They may 
pass from one part of the brain to another part, the 
sensory association fibers in the brain. 

Broadly speaking the conscious reception by the 
brain of a stimulus defines a sensation, but as afferent 
impulses may pass to the central endings of the nerves 
stimulated, from thence to a motor center, whereby 
an efferent impulse is dischaiged and an action re- 
corded without our knowledge, the term is not strictly 
correct, for the impulse is exactly the same over the 
first neuron and frequently the same over the second 
neuron as when we are conscious of these reflex acts. 

The centers in the cord are capable of recognizing 
the nature of impulses entering and act accordingly, 
be it for a simple muscular act or for a more important 
impulse through the cardiac or respiratory centers. 

Sensory impressions are those impressions which 
have their origin in special endings in the skin, mucous 



NERVOUS SYSTEM 177 

membrane, etc., or those having origin in special cells, 
as those of the retina, cochlea of the ear, etc., and are 
carried to the special centers in the brain, these latter 
are called nerves of special sense. 

Automatic Acts — 

Should a center as the respiratory or a tissue like 
the muscles or the nerves contained therein, be capable 
of sending out impulses without any influence being 
made upon them from without, that is, such im- 
pulses are endogenous as to origin in such a center 
alone, then we can truthfully call them automatic. 

Sympathetic Nerve System. 

This is a special division of the general nervous system 
distinguished by the interposition of ganglia, between the 
spinal motor nerves and the parts supplied. 

By virtue of the distribution of the fibers from the 
ganglia to the parts supplied, it may be inferred that the 
activities of the vascular and visceral muscles, either in the 
way of inhibition or augmentation, also the activities of the 
hair follicles, and of the epithelium of the glands, are called 
forth by consequence of the arrival of nerve impulses com- 
ing from the spinal cord through the preganglionic fibers, 
i. e., fibers from the spinal nerves to the ganglia. We thus 
have two neurons from the cord to the part supplied. 

The term autonomic nerve system has lately been ap- 
plied to this system of efferent nerves to indicate that they 
are in a certain sense independent of the cerebral nervous 
system. These fibers supply the plain muscular fibers (in- 



178 APPLIED PHYSIOLOGY 

voluntary), cardiac muscle and glands, while the spinal 
nerves supply the voluntary muscles.. It is quite evident 
that any alteration in any nerve fiber, in its cell of origin, 
or any stimulus which may modify the impulses, will cause 
changes in the response in the parts supplied; such condi- 
tions furnish us with most of the symptoms with which we 
have to do in disease. 

A lesion destroying a nerve or tract causes degeneration 
distal from the lesion, while the part connected to the cell 
of origin is little or late affected. 

Reflex Arc — 

Consists of at least a sensory neuron and a motor 
neuron. For a reflex arc we must have in addition 
to the anatomical parts named a stimulus acting 
upon sensory endings in skin, etc., and a response 
by motor endings in muscle, etc. 

Reflex arcs — 

i — Simple as in movement of a single muscle. 
2 — Co-ordinated reflexes. 
3 — Convulsive reflexes. 

LESIONS OF MOTOR NERVES. 

As a result of degeneration of a motor nerve or of 
altered irritability the extent of the lesion is often diagnosed 
by use of electrical stimulation, when the muscles supplied 
by said nerves will show the reaction of degeneration, in 
which cases the responses are opposite to those in normal 
muscle, viz., the degenerated nerve gives a reaction in 
muscle, KCC is less than ACC, and AOC is less than KOC. 



NERVOUS SYSTEM 179 

I — It is permissible in indubitable DeR (reaction of de- 
generation) to assume that a morbid process of the 
peripheral motor neuron exists. 

2 — DeR is usually absent in affections of the spinal 
cord, rarely present in cerebral diseases. 

3 — If no DeR in area of motor paralysis, it does not 
follow that the paralysis is not of a peripheral char- 
acter. 

4 — If the irritability of the nerve to electric stimula- 
tion has been considerably affected, a rapid improve- 
ment of the paralysis cannot be counted upon; the 
more DeR the less certain of a favorable termina- 
tion. The final effect of interrupted conductivity 
of motor and sensory tracts, i. e.., paralysis or an- 
aesthesia, is the same whether the cause is in the 
brain, spinal cord, or in the peripheral neuron. 

Peripheral Paralysis shows DeR. 

Atrophy of the parlyzed muscles, which become flaccid. 

Mixed nerves show simultaneous motor paralysis and 
sensory anaesthesia in the area of distribution of 
the affected nerves. 

Partial sensory paralysis usually absent. 

Reflexes entirely absent in affected area, if reflex arc 
is totally severed by nerve lesion. 

Direct manifestation as to whether cerebral or spinal 
affection entirely absent in pure forms of peri- 
pheral paralysis. 



180 APPLIED PHYSIOLOGY 

Central Paralysis — 
Absence of DeR. 

Muscles do not degenerate ; they show a spastic condi- 
tion. 

Anaesthesia and motor paralysis may exist inde- 
pendently, although sensory and motor fibers 
are present in nerve trunks of the part affected. 

Partial central paralysis is quite common. 

Certain types of paralysis are unmistakable, as para- 
plegia, hemiplegia, etc. 

Reflexes preserved in area of paralysis ; may be in- 
creased. 

Besides paralysis, eventual presence of psychical 
disturbances, headache, aphasia, urinary, rectal, 
etc., symptoms. 

LESIONS OF SENSORY NERVES. 

Pain — 

Under normal conditions it requires powerful stimu- 
lation to produce pain. By "eccentric projec- 
tion" pain is projected to the periphery. 

General cause of pain perception should be looked 
for in the total of stimulation — summation of 
stimuli. 

Intensity depends upon the amount and duration ; 
number of fibers and ganglion cells stimulated 
and upon their irritability. 



NERVOUS SYSTEM 181 

Character of Pain — 

Acute — Acute inflammations of serous membranes 
and synovial membranes. Radiating in neural- 
gias, inflammations and pressure. 

Dull — Inflammations of mucous membranes, paren- 
chymatous viscera and many chronic inflamma- 
tions. 

Paroxysmal — Neuralgias and colics ; many radiating 
pains and paroxysmal. 

Boring — In disease of the spinal cord, aneurysm, in- 
flammations of bone, carcinoma, and gouty con- 
ditions. 

Cramp — Sudden pain with full cramp of the muscles. 
Occupation cramp, as in writer's cramp from 
overuse. 

Abdominal cramp due to excessive action of 
muscles of stomach and intestines, flatulence, 
obstruction in the bowel, irritant poisons, etc. 
Tenesmus — A term applied to pain of inflamed blad- 
der and rectum, giving a sensation of bearing 
down. 

Abdominal Pain — 

All pains originate in the abdominal wall, more 
especially in the parietal serous membrane and sub- 
serous connective tissue structures which are inner- 
vated by the cerebro-spinal nerves. Chemically dif- 
ferent substances as contents of the stomach, gall 
bladder, intestine or abscesses give rise to severe 
pains when they come in contact with a healthy or 



182 APPLIED PHYSIOLOGY 

hyperaemic parietal peritomeum (pain due to perfor- 
ation) . — Lennander. 

Pain may be felt at the seat of disturbance or 
may be reflex (transferred pain). 

Reflex Pain — 

(a) Pain at the furthest peripheral termination of 
the nerve, when the lesion is at one of termina- 
tions near the origin of the nerve. 

(b) When irritation is at the termination of one 
branch situated in a different region from the 
pain. 

(c) When the irritation is at the origin of the nerve 
trunk, and the pain is referred to the peripheral 
distribution. 

Transferred pain (referred pain) may not be re- 
flex in the strict sense, when a transferred sen- 
sation is perceived by a sensory nerve and be- 
cause of indirect sensory connections along 
which the impression is referred to an entirely 
different portion of the periphery. 

Headache — 

A term applied to pain in the head without any 
special significance as to cause, may be due to neu- 
ralgia, a neuritis, inflammation of the cerebral struc- 
tures, pressure of tumors, a neurosis, reflex, or part of 
a general infection. 

Anaesthesia — 

Abnormal reaction of sensory nerves showing 
a diminished irritability. 



NERVOUS SYSTEM 183 

Hyperaesthesia — 

Abnormal reaction of sensory nerves with in- 
creased sensibility. 

Neuralgia — 

When irritants are not from the periphery. 

When the pain persists after the removal of the 

nerve externally. 
When localized to the distribution of the individual 

nerves. 

The pain occurs in attacks. 

Attacks probably due to summation of weak irri- 
tants. 

Paraesthesia — 

Abnormal sensations as formication, tickling, etc. 
Feeling- not in keeping with kind and intensity of 
irritation. 

Pain and Temperature Sense may be abnormal in lesions 
of the spinal tracts of Flechsig and Gowers. 

Touch Sense may be disturbed by lesions of the posterior 
spinal tracts. 

Muscle Sense may be disturbed by lesions of the long 
ascending posterior and lateral tracts of the cord. 

That sense through which we become aware of 
the position of any of our limbs without the aid 
of vision, as well as of any degree of motion of them. 
This power is diminished in diseases of the cord 
especially. By the muscular sense the paretic says 



184 APPLIED PHYSIOLOGY 

that his leg is heavy. And by this sense we esti- 
mate the amount of strength demanded by any mus- 
cular contraction and thus measure difference in the 
weight of objects, eliminating sense of pressure how- 
ever. 

Cutaneous Sensations — 

Partial paralysis signifies a loss of only a part 
of the general sensations : pain, temperature and 
pressure. Due to disturbances of the central me- 
chanism of brain and especially of the cord, not to 
peripheral lesions. 

Pains in anaesthetic areas are due to the fact that 
a part is anaesthetic as in peripheral paralysis, and 
the pain perceived is "eccentric projection" from the 
irritation of lesion in the cord. 

An "after sensation" is a prolonged sense of 
pain which succeeds a momentary impression. Seen 
in diseases of the spinal cord, especially progressive 
locomotor ataxia. 

A peculiar reversal of the sense of temperature 
is sometimes seen in diseases of the medulla, in lo- 
comotor ataxia, and in syringo-myelia. 

Vaso-Motor and Trophic Phenonema — 

Pathology has yet failed to separate lesions of 
the two sets of the vaso-motor nerves, constrictors 
and dilators and clinically the dilators are frequently 
looked upon as results of paralysis, or irritation of 
the constrictors. 

Vaso-motor paralysis seen in feeling of warmth, 



NERVOUS SYSTEM 185 

often actual elevation of temperature, sweating in 
circumscribed areas of half of the body. By the 
term paralysis here is meant a temporary inhibition 
of the action. 

Vaso-motor irritation is seen in pallor, coldness, 
stiffness, formication, and even pain. These are the 
phenonema of vaso-motor spasm. 

Symptoms of vaso-motor paralysis occur in con- 
nection with cerebral and spinal lesions and with in- 
juries to the sympathetic system which include vaso- 
motor nerves. 

The cause of the vaso-motor spasm is less easy 
to locate; it is associated with prolonged convul- 
sive seizures, and is seen in angina pectoris at the 
beginning of the attack, as if caused by an irritation 
of the sympathetic ganglia of the heart. 

Trophic or nutritive phenonema are closely 
allied to vaso-motor phenonema; they are probably 
under the control of these nerves. 

Disturbances of trophic functions are seen in 
such phenonema as vesicular eruption in the course 
of nerves (herpes zoster, etc.), pigmentations, sclero 
derma and glassy skin, changes in the hair, nails, 
etc. Many of these symptoms classed as trophic in 
origin are due to distinct lesions of the spinal cord 
or cerebrum. 

Bed Sores — No doubt that many of these lesions which 
begin as an erythematous patch on which bullae and blebs 
are rapidly developed, and which are followed by gangrene, 
are more easily invited in spinal paralysis than in the non- 



186 APPLIED PHYSIOLOGY 

paralytic conditions. These may be caused by cerebral 
lesions of the medulla, spinal cord and sympathetic. 

SPECIAL FORMS OF ANAESTHESIA. 

Smell- 
Loss of smell (anosmia). 

Due to disturbances of peripheral or central parts. 
When due to disturbances in the nerve-endings as 
rhinitis, the amount of nerve disturbance can- 
not always be made out. 

Anosmia generally due to peripheral causes as in- 
flammation, tumors, injuries, etc. 

Hyperosmia — Abnormal sensitiveness frequently due 
to neurotic conditions. 

Taste- 
Taste is normally perceived by special taste buds in 
the upper surface of the tongue; found also in 
the soft palate, uvula, anterior pillars of the 
fauces, and surface of the epiglottis. 
Sense of taste is confined to sensations arising from 
four distinct stimuli: (i) sweets, (2) bitters, 
(3) acids, (4) salt. 

Innervation of taste buds is from branches of the 
5th, 7th and 9th cranial nerves. 

Loss of sense of taste (ageusia) — 

May be seen in central lesions as in aphasia 
or in lesions of all or part of any of the nerves 
supplying the taste buds. 



NERVOUS SYSTEM 187 

Lesions of the fifth, generally an affection of the 
trunk of the nerve at the base of the skull. 

Lesion of the seventh cranial nerve generally in the 
petrous portion of the temporal mone, due to cold, 
diseases of the temporal bone, ear, etc. 

The taste fibers are not present in the nerve at 
the exit at the styloid foramen, but leave the 
nerve in the chorda-tympanic branch. 
Lesion of the ninth shows disturbance of taste, 
probably due to fibers derived from the fifth as a 
lesion of the root of the ninth is not followed by 
loss of taste. 
Parageusis — A perversion of the loss of taste. Rare, 
and seen in patients with facial palsy, in the 
hysterical and insane. 

Sight- 
Disturbance of function of sight may be confined 
to some part of the optic nerve, optic tract and centers 
of sight, or it may be due to lesions of the optic nerves 
as the motor oculi, which will prevent the proper re- 
ception of light into the eyeball. 

Hemianopia — Half blindness due to a lesion affect- 
ing one-half of the fibers in the chiasm, a complete 
lesion of one of the optic tracts or of the cortical visual 
center on one side. 

Complete blindness is due either to lesions of both 
eyes, both nerves, both tracts, entire chiasm, or both 
tracts or centers in both sides. 

Blindness of one eye is due to a lesion of one 



188 APPLIED PHYSIOLOGY 

eye or to one of the optic nerves. Hemianopia may be 
due to functional disease. It is seen as a transient 
symptom sometimes in migraine, either apart from 
headache and gastric disturbances or associated with 
them. 

Hearing — 

Deafness may be congenital, when it is due to labyrinth 
defect. 

Acquired nervous deafness is mostly due to diseases of 
the labyrinth, primary or secondary to diseases of 
the middle ear. 

May be due to lesions of the nerve trunks, due to de- 
generations as seen in locomotor ataxia, or com- 
pressed by thickenings of the cranial bones, tumors 
and extravasated blood. 

May be due to tumors and blood clots upon the nuclei 
in the pons. Rarely a disturbance of fibers from 
nuclei to cortical centers. 

Acuteness of hearing may be seen in lesions of the 
seventh, where the lesion is near the auditory 
nerve. 

LESIONS IN CORD. 

In an interruption of the pyramidal tract (pons, crus 
cerebri, cerebrum) above the decussation, hemiplegia of the 
opposite side occurs with a tendency to greater tension and 
contraction in the paralyzed muscles ; secondary degenera- 
tion descending, from lesion in the pyramidal tracts (an- 
terior of the same side crossed pyramidal of the opposite 



NERVOUS SYSTEM 189 



side). Peripheral nerves do not degenerate nor do the 
muscles atrophy. 

Lesions of the pyramidal tracts of the spinal cord, i. e., 
the central motor neuron may be assumed l if paralysis or 
paresis of the extremity exists without atrophy of the 
muscles, tendency to spastic contractures being present, also 
increased irritability (especially tendon reflex) and normal 
electrical reaction of the nerves and muscles. Sensation is 
intact. 

When the anterior cornu ganglion cells are affected 
by spinal-cord affection or alone injured there is flaccid 
paralysis with atrophy of the muscles and the peripheral 
nerves degenerate. 

Lesions of the anterior horn, i. e., the beginning of the 
peripheral motor neuron produces flaccid paralysis of the 
extremities with atrophy of the muscles, signs of DeR., 
reflex irritability suspended when the morbid process has 
reached a marked extent. 

Lesions of the posterior nerve roots and cornua — As a 
result of the disease of the posterior nerve roots, there is 
less of sensation of every quality, i. e., there exists a total 
anaesthesia in the cutaneous field supplied by the affected 
root; sensory ataxia; cessation of reflexes with preserved 
motility; expect absence of sensation of urinary pressure. 

Lesion of the posterior cornua — Disturbances of the 
vasomotor innervation (trophic disturbances) partly also in 
the tactile-sense in the skin, less heat and pain and eventu- 
ally sensory ataxia ; muscle-sense and motility remain intact ; 
reflexes may be partly impaired. 

Lesions of the posterior columns — Disturbance of 



190 APPLIED PHYSIOLOGY 

muscle tonus, muscle sensation and sensory ataxia; reflex 
irritability may be diminished; may be incomplete urinary 
pressure and disturbance in the excretion of urine. 

Lesion of the anterolateral ground bundles — Nothing 
definite. 

Lesions of the lateral cerebellar tracts — Disturbances 
of co-ordination and reflexes. Motility preserved. 

Acute Spinal Meningitis — 

Fixed pains along vertebral column and pains 
which radiate to the trunk and body. Hyperaesthesia 
of the skin and muscles. Stiffness of vertebral column ; 
partly due to muscle spasm, caused by irritation of the 
anterior roots and partly reflex. In muscles of neck 
it is called rigidity; in abdominal muscles, scaphoid re- 
traction of the abdomen; in extensors of the back, 
opisthotonus. 

Later — Cutaneous and tendon reflexes are lost; 
paralysis and anaesthesia. These due to great pres- 
sure upon the nerve roots. 

Special symptoms are due to the location of the in- 
flammation. Fever is not characteristic in type. Never 
diagnose spinal meningitis if one of the recognized 
causes cannot be proven to be present; said cause may 
be the reason of many of the apparent meningeal symp- 
toms. 

Locomotor Ataxia — 

Lightning pains — Due to irritation of the sensory roots. 
Lost tendon reflexes — Break in the reflex arc, chiefly 
sensory roots. 



NERVOUS SYSTEM 191 

Argyll-Robertson pupil — Lesion probably in Mynert's 
fibers, passing from the anterior corpora quad- 
rigemina to the nucleus of third cranial nerve. 

Crises — Gasric, intestinal, vesical and laryngeal, due 
to irritation of the sensory roots and to an accom- 
panying neuritis. 

Ataxia due to lesion of the posterior columns ; disturb- 
ance of the muscle sense, etc. 

Paralysis of the legs, bladder, etc., due to advancing 
degeneration of the pyramidal tracts and super- 
added neuritis. 

Arthropathies — A trophic disturbance. Probably due 
to interruption in the conduction and to degenera- 
tion of the sensory nerves supplying the joints. 

Amytrophic Lateral Sclerosis — 

Pyramidal tracts degenerated. 

Motor sphere severely damaged. 

Spastic paretic gait. — (See above). 

Tendon reflexes greatly increased. Due to removal of 
cerebral inhibitory control. 

Later — Atrophy of the muscles en masse, due to 
changes to a slight degree in the motor ganglion 
cells of anterior cornua ; at first appears in the 
upper limbs. 

Anterior Poliomyelitis — 

Affection of the anterior cornua ganglionic cells. 
Symptoms principally limited to the peripheral motor 
neuron. 



192 APPLIED PHYSIOLOGY 

Acute anterior poliomyelitis — High fever due to infec- 
tion. 

Paralysis — Both legs, arm and legs, half body, arm on 
one side and leg on the other, one arm and one leg, 
or either. 

Location of the symptoms depends upon the extent of 

the lesion. 
Paralysis flaccid, never spastic, followed by atrophy. 
Reflexes lost. Sensation good. Sphincters intact. 
Contractures, club foot, etc., due to action of antagon- 
istic muscles not affected. 

Bulbar Paralysis — 

A progressive condition. 

Difficulty in articulation of words containing letters 
which require the use of the tongue; later those 
requiring the use of the lips. Due to involvement 
of the motor nuclei in the medulla. 

From motor involvement the muscles become wasted. 
Tongue and lips waste. 

Difficulty in swallowing, from involvement of the nuclei 
of the ninth and tenth cranial nerves in the me- 
dulla. 

He cannot speak, hence he grunts. He cannot swallow, 
hence food may enter the larynx, frequently caus- 
ing pneumonia or suffocation. He cannot close his 
mouth, hence the lower part of his face is motion- 
less and expressionless, and upper part of his face 
manifests suffering and anxiety.. He cannot spit, 






NERVOUS SYSTEM 193 

hence saliva runs from the mouth. Pain and an- 
aesthesia are absent. 

Apoplexy — 

Due to cerebral hemorrhage. 

Apoplectic stroke — The loss of consciousness depends 
upon the localization and extent of hemorrhage. 

Breathing slow and stertorous — Involvement of im- 
pulses from the brain to the center. Noisy puffing 
sound on breathing, due to blowing out of re- 
laxed cheeks on the paralyzed side. 

Motor paralysis generally hemiplegia of the opposite 
side — Due to* involvement of the pyramidal fibers. 
Facial paralysis is on the same side, if the lesion in- 
volves the tract above the decussation., 

If the tongue is involved, it points to paralyzed side 
when protruded. 

Pupils are irregular, sometimes contracted, often di- 
lated, unequal. 

Pupils respond to light slowly or not at all. 

Position of the eyeball in various lesions of the cere- 
brum. 

Conjugate deviation of the eyes and head is dependent 
on a most complex mechanism. — (Weisenburg). 

Conjugate deviation towards lesion without spasm, due 
to lesion in the cortex. 

Conjugate deviation from lesion with spasm, due to 
lesion in cortex. 

Conjugate deviation without spasm or toward lesion 



194 APPLIED PHYSIOLOGY 

with spasm, due to lesion of internal capsule or 
pons. 

In health the eye movements are innervated from both 
sides. 

When a lesion occurs on one side of the brain the inner- 
vation is given over to the other side until the 
injured one resumes its function. May even ex- 
ceed its function.. 

Faeces and urine are passed involuntarily, retention or 
incontinence due to cutting off of cerebral influ- 
ences. 

Reflex action suspended. 

Tumors of the Brain — 

Headache — Neither the seat nor the nature of the path 
is characteristic. May be increased by tapping 
the skull. 

Vomiting — Generally most violent when it is centric, 
due to tumors, situated in the pons or cerebellum, 
making pressure upon the center or altering the 
blood supply of the part. 

Apoplectiform attacks — Generally due to hemorrhage 
from the tumor or around it. 

Choked disc — Probably due to intracranial pressure 
forcing cerebro-spinal fluid from the arachnoid 
space into the lymph sheath of the optic nerve, 
causing compression of the nerve and vessels which 
flow through it. 

Senses of smell, taste and hearing are altered when 



NERVOUS SYSTEM 195 

tumors impinge upon these nerves or involve their 

centers. 
Glycosuria — When the tumor is in the floor of the 

fourth ventricle. 
Special symptoms due to particular location of the 

tumor as: 

Aphasia — Tumors of the lower frontal, temporo- 
sphenoidal and parietal regions. 

Sight — Tumors of the occipital region and those 
affecting the primary centers. 

Hearing — Tumors in the temporo-sphenoidal 
region and those affecting the primary cen- 
ters. 

Muscle spasm — Tumors of the central region; 
tumors involving motor tract anywhere from 
the motor cortex to the medulla. 

Tumor of the Pons — 

Paralysis — Generally cranial of one side and body of 
the other. 

Irritations (spasms, twitchings, etc.) generally cranial 

one side and body of the other. 
Palsy of the third cranial nerve of the left side with 

hemiplegia of the right side, when the tumor is 

high on the left side. 

the left side. 
Palsy of the fifth cranial nerve of the right side with 

hemiplegia, when the tumor is low on the left side. 
Palsy of the sixth cranial nerve, producing internal 

strabismus of the left eye and external stabismus 

of the right eye and palsy of the seventh cranial 

nerve of the left side, when the tumor is very low 

on the left side. 



196 APPUED PHYSIOLOGY 



BIBLIOGRAPHY. 

American Journal of Physiology. 

Babcock — Diseases of the Heart and Arterial System — 1903. 

Bartley — Clinical Chemistry, Second Edition — 1904. 

Beebe — Physiology of the Thyroid Gland, etc. — Jour. A. 
M. A, Oct. 5th, 1907. 

Cabot — Clinical Examination of the Blood, Fourth Edi- 
tion — 1 90 1. 

Caille — Differential Diagnosis and Treatment of Disease — 
1906. 

Calvert — Pulsus Paradoxus in Pericarditis With Effusion — 
Jour. A. M. A., April 6th, 1907. 

Cannon — Passage of Different Foodstuffs From the 
Stomach — Jour. A. M. A., January 7th, 1905. 

Cannon — Recent Advances in the Knowledge of the Move- 
ments and Innervation of the Alimentary Canal — 
Medical News, May 20th, 1905. 

Cohnheim, Paul — The Different Forms of Hyperchorhydria 

— N. Y. Medical Journal, October 12, 1907. 
Da Costa — Chemical Hematology, 1902. 
Dana — Text Book of Nervous Diseases, Fourth Edition — 

1897. 

Emerson — The Pathology of Function, an Experimental 
Laboratory Course — N. Y. Med. Jour., April 20th, 
1907. 

Erlanger — Recent Contributions to the Physiology of the 

Circulation — Jour. A. M. A., October 27th, 1906. 
Green — Pathology and Morbid Anatomy — 1895. 

Hall — Pathologic Physiology, a Neglected Field — Jour. 
A. M. A., December 30th, 1905. 



BIBLIOGRAPHY 197 

Hall — Text-Book of Physiology, Normal and Pathological, 

Second Edition — 1905. 
Hare — Practical Diagnosis — 1896. 

Hay and Moore — Stokes-Adams Disease and Arrhythmia — 
Lancet, November nth, 1906. 

Howell — Text-Book of Physiology, Second Edition — 1907. 

International Text-Book of Surgery — 1902. 

Janeway — Clinical Study of Blood Pressure — 1904. 

Janeway — Some Common Misconceptions in the Patho- 
logic-Physiology of the Circulation — N. Y. Med. 
Jour.. February 2d, 1907. 

Journal of Physiology. 

Landois — Text-Book of Human Physiology, Tenth Edition 

—1904. 
Lazarus-Barlow — Manual of General Pathology, Second 

Edition — 1904. 
Lennander — Abdominal Pain — Jour. A.. M. A., September 

7th, 1907. 

Leube, translated by Salinger — Medical Diagnosis — 1907. 

Lusk — Science of Nutrition — 1906. 

Mathews, A. P. — Theory of the Nature of Protoplasmic 
Respiration of Growth — Biological Bulletin, May, 
1905. 

Meltzer — Edema- — American Medicine July 2-30, 1905. 

McCaskey — Heart Block — Jour. A. M. A., March 30th, 
1907. 

Pawlow — Digestive Glands, translated by Thompson, 1902. 

Pillsbury — Reduplication of the Heart Sounds — Jour. A. 

M, A., December 29th, 1907. 
Purdy — Practical Urinalysis, etc. 

Rhodes — Physiology of Temperature, etc. — American Jour- 
nal of Obstetrics, Vol. LIIL, No. 1, 1906. 



198 APPLIED PHYSIOLOGY 

Rhodes — Carbohydrate Metabolism — American Medicine, 
December ioth, 1904. 

Sajous — Internal Secretions and the Principles of Medicine, 
Vol. I., 1903. 

Sewall — Experiments on the Blood Pressure, and Its Rela- 
tions to Arterial Pressure in Man — Jour. A. M. A., 
October 20th, 1906. 

Simon — Physiological Chemistry, Third Edition, 1907. 

Sterling — Recent Advances in the Physiology of Digestion, 
1906. 

Stewart — Manual of Physiology, Fifth Edition, 1905. 

Taylor, J. Madison — Physiology the Basis of Clinical Medi- 
cine. Suggestions as to Courses in Applied Physi- 
ology — The Medical News, May 13th, 1905. 

Tigerstedt, translated by Murlin — A Text-Book of Human 
Physiology — 1906. 

Thomsen — Internal Secretions — N. Y. Med. Jour.., Novem- 
ber 19th, 1904. 

von Neusser — Dyspnoea and Cyanosis, translated by Mac- 
Farlane, 1907. 

Williams — Effects of Respiration Upon the Circulation, etc. 
— British Med. Jour., August 17th, 1907. 

Wood — Therapeutics, Its Principles in Practice, Twelfth 
Edition, 1905. 

Weisenberg — Conjugate Deviation of the Eyes and Head, 

etc. — Jour. A. M. A.., March 23d, 1907. 
Zeigler — General Pathology, Tenth Edition, 1903. 
Zeitschrift fur Physiologische Chemie. 



INDEX. 



199 



INDEX. 



Abdominal pain 181 

Acid, eructations 113 

hippuric 153 

hydrochloric 108, 117 

in gastric juice 113 

oxalic in urine 154 

reaction in saliva 102 

uric 132, 153 

Acids, biliary 130 

Addison's disease 137 

Adrenal's 137 

Air passages, diseases of 81 

function of 81 

obstruction in 81 

reserve . 67 

residual 67 

stationary 68 

tidal 67 

Albuminuria, febrile 165 

forms 164 

in heart disease 165 
in pregnancy... 165 

physiologic 166 

in tuberculosis 96 

Albumosuria 167 

Anacrotic pulse 20 

Anaesthesia 182 

Anemia 58 

effect of upon body 62 

primary 58 

secondary 58 

Aneurysm 35 

aortic symptoms. 35 

cause 35 

cause o f body 

murmurs 21 

Angina pectoris, from hard 

arteries, etc... 20 

symptoms 23 

Angio - neurotic - oedema of 

larynx 84 

Anorexia 110 

Anosmia 186 

Anterior spinal tracts, le- 
sions of 189 

Antipiretics 147, 150 



Aortic, regurgitation 33 

stenosis 32 

Apex beat, altered by 11 

systolic retrac- 
tion of 28 

Aphasia 195 

Aphonia in pericarditis 27 

Apnoea 74 

Apoplexy 193 

Appendicitis 126 

Appetite Ill 

Argyll-Robertson pupil 191 

Arrhythmia 12 

Arterial pressure in pericar- 
ditis 28 

Arteries, normal pulsating.. 21 
pulsating in heart 

disease 34 

Arterio-sclerosis, sequelae... 35 
symptoms 34 

Artificial respiration 68 

in chloroform 
asphyxia... 75 

Arthropathies 101 

Ascites 139 

in diseases of the 

pancreas 134 

in leukemia 62 

Asphyxia 40, 42 

cause of less urine 157 
Asthma, Charcot's crystals 

in 93 

Curschman's spir- 
als 93 

heart in 93 

pulse in 93 

symptoms of 92 

Ataxia 189, 192 

Atheroma, cause of high ar- 
terial tension -. 20 

Atropine causing disturb- 
ances of salivation 103 

Atrophy, muscular in cere- 
bral lesions 179 

muscular in spinal 
lesions 189,192 



200 



INDEX. 



Auerbach's plexus 120 

Automatic acts 177 

Bacteria, effect upon res- 
piration 79 

Bed sores 185 

Biliary substances in stools. 128 

acids 130 

colic 133 

Biot's respiration 77 

Bladder in spinal lesions..l89-192 
cerebral lesions ..159,161 

Blindness.. 187 

Blood, alkalinity altered. 39, 47... 

color 39 

corpuscles 38, 42 

in asphyxia 40 

in drowning 40 

in poisoning 40, 41 

in stools 123 

in urine 168 

quantity 44, 47 

reaction 39 

specific gravity 37 

transfusion 45 

Blood pressure after hemor- 
rhage 58 

after saline 

injections.. 17 
factors regu- 
lating 17 

in pericardi- 
tis 28 

reflex action 

in 17 

vaso motor 
tone in .... 17 
Bone marrow, function of .. 59 
Brain lesions affecting urin- 
ation 150, 160 

tumors of 194 

Breath foetid 104, 116 

Breathing in apoplexy 193 

types of 167 

Bronchitis, chronic 89 

fibrinous 89 

heart affected by 88 
lungs " " 88 
portal system af- 
fected by 87 

Bronzing of skin 137 

Bruit-de-gallop 14 



Bulbar paralysis 84, 193 

cause of sal- 
ivation ... 103 

Caisson disease 76 

Canter rhythm 14 

Capillary blood pressure 18 

Caput medusae 139 

Carbon dioxide, effect of in- 
crease.... 74 
in fever .... 144 

Carcinoma of stomach 117 

of oesophagus ... 106 

Cardiac dilatation 11 

murmurs 60 

valves, lesions of ... 30 

Cardialgia 115 

Casts, bronchial 89 

in urine 171 

Catarrhal diarrhoea 121 

Cheyne-Stokes respiration . 76 
Children, incontinence of 

urine in 161 

Chill in pneumonia 90 

Chlorides in urine 153 

Chloroform inhalation 75 

Chlorosis 60 

Choked disc 194 

Cholelithiasis 133 

Chyle 53 

Circulation 7 

Circulatory apparatus 7 

Cirrhosis of liver 132, 135 

Club-foot 192 

Coagulation of blood 49 

Colic, biliary... 133 

Compensation in heart dis- 
ease 30 

Constipation, due to 123 

in peritonitis. 139 
symptoms .... 124 

Convulsions in anemia 63 

Coprastasis 125 

Corpuscles, blood 38 

forms 38 

red,crenation of 38 
red. altered in 

number 42, 47 

red, nucleated.. 38 
white, altered in 

number 42 

blood, origin of. 59 



INDEX. 



201 



Coryza 82 

Cough, affecting expiration. 70 
affecting intrapul- 

monary pressure .. 70 
affect ing venous 

pressure 70 

in aneurysm 36 

in bronchitis 87 

in pneumonia 89 

reflex 73, 84 

Cramps 181 

Creatinin in urine 153 

Cretinism 137 

Croup, pseudo 121 

Crystals, Charcot' s 93 

Cyanosis 59, 82 

in emphysema 91 

Deafness 188 

Defecation 123 

Deglutition 104 

in bulbar paral- 
ysis 192 

Degeneration, reaction of... 179 

Desmoid reaction 107 

Deviations, mental 174 

Dextrose in blood 56 

Diabetes, affecting urine.... 162 
in disease of pan- 
creas 134 

Diarrhoea, catarrhal 121 

in dyspepsia. 11 6, 121 

in peritonitis 139 

in tuberculosis... 96 

nervous 121 

spurious 122 

toxic 121 

vicarious 121 

Diazzo reaction 169 

Dichrotic notch 19 

pulse 19, 

wave 18 

Diet in production of heat.. 142 

Digestion 99 

Diphtheria 86 

Diuretics 156 

Drugs, affecting color of 

urine 163 

Dyspepsia 104, 115, 118 

Dysphagia 105 

in laryngitis 83 

in pericarditis .... 27 



Dyspnoea 67, 73 

cardiac 98 

causes 77 

forms 78 

from foreign bod- 
ies 81 

in aneurysms 36 

in bronchitis 87 

in emphysema 91 

in Hodgkin's dis- 
ease 62 

in myocarditis .... 27 

in pericarditis .... 27 

in pharyngitis .... 83 

in renal 98 

in tuberculosis .... 94 

with cyanosis 78 

without cyanosis. 78 

Eccentric projection of pain 180 

Emphysema 70, 91 

Endocarditis, acute 29 

chronic 29 

loss of com- 
pensation in. 30 
Enteritis, acute catarrhal ... 125 

Epiglottis, destruction of. ... 84 

immotility of.... 85 

Epistaxis in leukemia 62 

Eructations, acid 113 

gaseous 113 

Ether inhalation 76 

Eupnoea 66 

Extractives of blood 56 

Eyes, deviation of 193, 195 

Fats in blood 57 

in stools 122 

in urine 170 

Feces in apoplexy 194 

incontinence of 125 

Ferments, digestive 101 

secretion of 100 

Fever 144, 147 

in tuberculosis 94 

Flatulence 112 

Food, improper preparation 101 
Foreign bodies in larynx ... 84 



202 



INDEX. 



Gait in spinal disease.... 189, 192 

Gallop rhythm 14 

Gaseous eructations 113 

Gastrectasis 118 

Gastric ulcer 116 

Glands 127 

Glottis, function of 83 

Glycosuria 131 

in disease of pan- 
creas 134 

in tumors of brain 195 

Haematuria 162 

Haemoglobin in blood 44 

Haemoglobinuria 162 

Haemolysis in pernicious 

anemia 61 

Haemoptysis 36 

causes of 97 

in bronchitis.. 88 
in tuberculosis 96 
Hall method of artificial res- 
piration 68 

Headache 182, 194 

in coryza 82 

in loss of com- 
pensation 30 

in neuroses of the 

stomach 119 

in pneumonia .... 190 

Hearing, acuteness of 188 

loss of 184, 194 

Heart 8 

action related to res- 
piration 71 

after hemorrhage 48 

block, symptoms 24 

hemisystole of 13 

hypertrophy 10 

in asthma 93 

in emphysema 91 

murmurs 14 

musculature 9 

reduplicated 13 

rhythm 9, 12 

sounds 12 

Hematoporphyrin 169 

Hemianopia 187 

Hemorrhage 45 

causing fall of 

temperature. 145 
forms of , 47 



Hemorrhage, continued. 

metabolism fol- 
lowing 47 

Hemorrhoids 128 

in cirrhosis of 

the liver 133 

Hiccough 115 

Hippuric acid in urine 153 

His, muscle bundle of 24 

Hoarseness 85 

Hodgkin's disease 62 

Howard method of artificial 

respiration 68 

Hydronephrosis, causing 

suppression 160 

Hydrops laryngismus 83 

Hyperaesthesia 183 

Hyperacidity 113 

Hyperchlorhydria, causes... 113 

forms 113 

results of. 113 

Hypernoea 73 

Hypernosis 49 

Hyperosmia 186 

Hyperthermia 149 

Hypoacidity 114 

Hypochlorhydria, causes ... 114 
results of 114 

Hypothermia 149 

Hysteria, cause of flatulence 110 
cause of vomiting. Ill 
causing suppres- 
sion of urine 161 

Icterus 128 

hematogenous 130 

in cholelithiasis 133 

in disease of the pan- 
creas 134 

in pernicious anemia 61 

neonatorum 129 

non-obstructive 130 

obstructive 129 

Ileus 125 

Indican 155, 169 

in disease of pan- 
creas 134 

Influenza 91 

Intestinal movements 120 



Jaundice (see icterus) 



INDEX. 



203 



Kidney, congestion of 152 

excretions from.... 151 

Laryngeal crises of locomo- 
tor ataxia 85 

dysphagia 105 

muscles, paraly- 
sis 85 

nerves, affections 

of 85, 86 

Laryngismus stridulus 83 

Laryngitis 83 

oedematous 84 

Larynx, food in 192 

foreign bodies in . . . 84 

oedema of 83 

stenosis 84 

Leucocytosis 42 

Leucopenia 42 

Leukemia 61 

Lights 68 

Lips, blue 40 

pale 40 

Litten's sign 92 

Liver, amyloid in disease of 

spleen 135 

cirrhosis in disease of 

spleen 135 

cirrhosisof 132 

functions of 127, 128 

Locomotor ataxia 190 

affecting 
urination 161 
Lungs affected by bronchitis 88 

vital capacity 67 

Lymph, formation of 52 

Malaria, causing large spleen 136 

fever in 150 

Meisner's plexus 120 

Melanin in urine 162 

Meningitis, acute spinal .... 190 

Mental deviations 174 

Mercury causing salivation. 103 

Micturition 158 

Mitral regurgitation 31 

regurgitation causing 
functional murmurs 16 

stenosis - 31 

Mountain sickness 76 

Mouth 100 

movements of 101 



Mucous membrane in stools 122 
Mucus, excess in stomach... 113 

in stools 122 

Murmurs heart, causes of... 15 
endocardial 15 
factors fa- 
voring 21 

functional.. 16 
in arterio- 
sclerosis . 35 
in body, 

seen when 21 
in myocar- 
ditis 27 

intensity of 15 
of abdom- 
inal aorta 134 
transmis- 
sion of 15 

Myocarditis, acute 26 

chronic 27 

Myxoedema 136 

Nausea 112 

Nephritis, affecting amount 

of urine 157 

causing high ar- 
terial tension ... 20 

Nerve impulses 175 

injury 174 

roots, posterior, le- 
sions of 189 

Nerves, motor 175 

motor lesions of 178 

recurrent, paralysis 

of 85 

respiration 65 

sensory 176 

sympathetic 177 

Nervous diarrhoea 121 

diseases, causes 174 

disease symptoms.. 172 

system 172 

system in regula- 
tion of tempera- 
ture 142 

Neuroses of the larynx 84 

of the stomach .... 118 

Neutrophilia 34 

Nitrogenous disturbances... 131 

Nose, changes in 81 

Nucleo-albumins 168 



204 



INDEX. 



Oedema 54 

causes 140 

forms 140 

from bronchitis 89 

i n carcinoma o f 

stomach 117 

in chlorosis 61 

in loss of compen- 
sation 30 

of larynx 93 

Oesophageal dysphagia 105 

Oesophagus, carcimona of... 106 

Oligemia 44 

Orthopnoea 78 

Osteosarcoma 167 

Oxygen absorbed in fever .. 144 
affect of diminished 

amount 74 

affect of increased 
amount 74 

Pain 180 

abdominal 181 

cause of constipation.... 134 

character of 181 

in angina pectoris 124 

in appendicitis 133 

in carcinoma of stom- 
ach 117 

in gastralgia 118 

in gastric ulcer 116 

in headache 182 

in intestinal obstruc- 
tion 125 

in locomotor ataxia 183 

in neuralgia 183 

in peritonitis 138 

in pneumonia 89, 90 

in tuberculosis 93, 96 

on defecation 123 

reflex 182 

sense 183 

transferred 182 

Pancreas, diseases of 133 

functions of 133 

in sugar destruc- 
tion 131 

Paraesthesia 183 

Parageusia ... 187 

Paralysis, cause of consti- 
pation 124 

central 180 



Paralysis, continued. 

from tumor of 
pons 195 

in apoplexy 193 

in spinal le- 
sions 189, 192 

peripheral 179 

Parathyroids 136 

Pentose in urine 169 

Pepsin 108 

Pericarditis 27 

Peritoneum 138 

Pernicious anemia 61 

Pharyngitis 83 

Pharynx, changes in 81 

Phosphates in urine 154 

Pigments 57, 155, 162 

Pigmentation 137, 185 

Plasma 151 

Plethora 44 

Pleura 65 

Pleurisy 91 

Pneumonia, bronchial 89 

lobar 90 

Pneumothorax 71 

Poikilocytes 38 

Polycythemia 37 

Poliomyelitis, anterior 191 

Pons, tumors of 195 

Polyuria 155 

Portal system, anastomoses 

of 128 

in bronchitis 89 

Pregnancy, albuminuria of. 165 

Pruritus 130 

Pulmonary tuberculosis .. .93, 96 

Pulse, alterans 23 

anachrotic 20 

Corrigan's 22, 23 

dichrotic 19 

differens 23, 36 

due to 18 

forms of 19 

slow 130 

supernumerary 22 

tardus 34 

venous 22, 34 

water-hammer 22 

Pupil, Argyll-Robertson 191 

in apoplexy 193 

Purin bodies in blood 57 



INDEX. 



205 



Pus in stools 122 

in urine 170 

Pyrosis 112 

Kales, forms .._ 86, 87 

in bronchitis 88 

Reaction of degeneration. 179, 180 

Reflexes action 178 

Reflexes in central paralysis 180 
in locomotor ataxia 190 
in peripheral pa- 
ralysis 179 

Renal symptoms in heart 

disease 31 

Respiration 64 

affected by bac- 
teria 79 

affected by mus- 
cular work 74 

affected by tem- 
perature 79 

artificial 68 

Biot's 77 

centers of 65, 73 

Cheyne-Stokes .. 76 
depends upon .... 80 

forms 64 

function of 80 

in emphysema.... 91 
movements of. 65, 73 
nerves of...-65, 72, 73 
related to heart 

action 71 

Respiratory movements, al- 
tered by 96 

organs, diseases 

of 79 

Rhonchus 87 

Saline solution, physiolog- 
ical 45 

Saliva, acid 102 

amount 102 

reaction 101 

Salivation, disturbances of.. 103 
nervous mechan- 
ism 102 

Salts, function of 55 

in urine 153 

Schaeffer method of artifi- 
cial respiration 68 



Sclerosis, amytrophic lateral 191 

Sense, muscle 183 

pain 183 

temperature 183 

touch 183 

Sensations, cutaneous 184 

Sibilus 87 

Sight 187 

Skin clammy 139 

Smell, acuteness of 186 

loss of 186, 194 

Speech, affected 192 

Spinal cord lesions 188, 192 

affecting urina- 
tion 159, 161 

Spirals, Curschman's 93 

Spleen, diseases of 135 

dislocated 137 

in Hodgkin's dis- 
ease 62 

in leukemia 61 

Sphygmogram 18 

Spurious diarrhoea 122 

Sputum in pneumonia 90 

in tuberculosis 95 

Stigmata, physiological 173 

Stomach, absorption power. 107 

function 107 

movements 109 

motility 107 

motor insufficien- 
cy 119 

nervous mechan- 
ism 109 

neuroses of 118 

Stools, abnormal substances 

in 122 

green 126 

odor of 123, 129 

water in 122 

Stridor 82 

Strychnine, causing rise in 

temperature 145 

Sugar, destruction of 56 

in urine 168 

Sulphates in urine 154 

Suppuration causing albu- 
mosuria 167 

Sweat in tuberculosis 96 

Sympathetic nerves 177 

Sylvester method of artifi- 
cial respiration 68 



206 



INDEX. 



Taste, bad Ill 

loss of 186, 194 

nerves of 186 

Temperature, affected by 

respiration. 71 
after hemor- 
rhage 48 

centers regu- 
lating 144 

effect of on vi- 
tal centers.. 145 
lowered after 

hemorrhage 145 
maintained .... 141 
production of. 141 

subnormal 147 

Tenesmus 181 

Test meal 108 

Tetany 136 

Thirst in dyspepsia 115 

in enteritis 126 

Thrombi 51 

Thymus 59 

Thyroid, removal of.. 136 

symptoms 136 

Tongue, coated 101 

in apoplexy 193 

Tonsillitis 81 

Toxic diarrhoea 121 

Tracheal stenosis 86 

Tricuspid regurgitation 34 

Tricuspid regurgitation caus- 
ing functional murmurs 16 

Trophic phenomena 184 

Tympanites in intestinal ob- 
struction 125 

in peritonitis .... 139 
Typhoid fever causing re- 
tention of urine 160 

Tumors, brain 194 

pons 195 

Uraemia 166 

Urates 170 

Urea, amount excreted.. 143, 152 

formation of 132 

in blood 57 

in urine 152 



Uric acid. 132 

in urine 153 

Urination, frequency of 158 

Urine 151 

abnormal substances 

in 153, 169 

casts 171 

color 162 

composition 152 

incontinence 159 

quantity 155, 157 

reaction 163, 164 

retention 160 

secretion 152 

suppression 161 

turpidity 163 

Vagus, in heart block 25 

Valves, changes in cardiac 

hypertrophy 10 

cardiac, lesions of .. 30 
in endocarditis 29 

Vasa motor phenomena 184 

Vena cava inferior, anasto- 
moses of 128 

Venous pressure affected by 

coughing 71 
influence of 18 

Venous hum 21 

Vicarious diarrhoea 121 

Vocal cords, paralysis of 85 

Vomiting in aneurysm 37 

in appendicitis .... 126 
in carcinoma of 

stomach 117 

in gastrectasis 118 

in gastric ulcer .... 117 
in hyperacidity.... 114 
in intestinal ob- 
struction 125 

in nerves acting 

reflexly 110 

in peritonitis 139 

in tuberculosis 95 

in tumors of brain 194 



ft 



X. i 



